CA2736929C - Inhibition of plgf to treat philadelphia chromosome positive leukemia - Google Patents

Abstract

The present application relates to the field of leukemias, and more in particular to how Pl GF inhibition can help to treat Philadelphia chromosome positive (Ph+) leukemias. Methods are provided for treating Ph+ leukemias by administering Pl GF inhibitors. Also disclosed are uses of Pl GF inhibitors in the treatment of Ph+ leukemias, or for the preparation of a medica-ment against Ph+ leukemias.

Description

Inhibition of PIGF to treat Philadelphia chromosome positive leukemia Field of the invention The present application relates to the field of cancer, in particular leukemia. More in particular, it relates to treatment of Philadelphia chromosome positive (Ph+) leukemia. This is achieved via inhibition of placental growth factor (PIGF). Thus, methods are provided for treatment of Ph+ leukemia using PIGF inhibitors, in particular using an anti-PIGF antibody. A particular type of leukemia that is envisaged to be treated this way is chronic myelogenous leukemia (CML), especially also in patients where conventional BCR/ABL inhibitors, such as imatinib, fail to have sufficient therapeutic effect.
Background Philadelphia chromosome, also known as the Philadelphia translocation, is a specific chromosomal abnormality that is associated with chronic myelogenous leukemia (CML). It is the result of a reciprocal translocation between chromosome 9 and 22, and is specifically designated t(9;22)(q34;q11). The presence of this translocation is a highly sensitive test for CML, since 95%
of CML patients have this abnormality. The remaining 5% of CML patients typically have either a cryptic translocation that is invisible on G-banded chromosome preparations, or a variant translocation involving another chromosome or chromosomes as well as the long arm of chromosomes 9 and 22.
However, the mere presence of the Philadelphia (Ph) chromosome is not sufficiently specific to diagnose CML, since it is also found in 25-30% of adult acute lymphoblastic leukemia (ALL) cases (and in

2-10% in pediatric ALL
cases).
Nevertheless, these diseases are clearly distinct. Acute lymphoblastic leukemia (ALL) is a form of leukemia in which malignant, immature white blood cells continuously multiply and are overproduced in the bone marrow. ALL causes damage and death by crowding out normal cells in the bone marrow, and by spreading (metastasizing) to other organs. ALL is most common in childhood and young adulthood with a peak incidence at 4-5 years of age, and another peak in old age. The overall cure rate in children is 85%, and about 50% of adults have long-term disease-free survival. 'Acute refers to the undifferentiated, immature state of the circulating lymphocytes ("blasts"), and to the rapid progression of disease, which can be fatal in weeks to months if left untreated. Treatment for acute leukemia can include chemotherapy, steroids, radiation therapy, intensive combined treatments (including bone marrow or stem cell transplants), and growth factors.

Chronic myelogenous (or myeloid) leukemia (CML) on the other hand is a form of leukemia characterized by the increased and unregulated growth of predominantly myeloid cells in the bone marrow and the accumulation of these cells in the blood; it is thus a myeloproliferative disease. CML is a clonal bone marrow stem cell disorder in which proliferation of mature granulocytes (neutrophils, eosinophils, and basophils) and their precursors is the main finding.
Historically, it has been treated with chemotherapy, interferon and bone marrow transplantation, although targeted therapies are now also available and used as standard of care.
The swapping of parts of chromosomes 9 and 22 observed in the Philadelphia chromosome gives rise to a BCR-ABL fusion gene (Melo, 1996). That is to say, part of the BCR
("breakpoint cluster region") gene from chromosome 22 (region q11) is fused with part of the ABL gene on chromosome 9 (region q34). Abl stands for "Abelson", the name of a leukemia virus which carries a similar protein. Two kinds of BCR-ABL transcripts (which yield p185 and p210 isoforms, named after their apparent molecular weight in kDa) are generated due to the breakpoint of the BCR region. The fused "BCR-ABL" gene is located on the resulting, shorter chromosome 22. ABL carries a domain that can add phosphate groups to tyrosine residues (a tyrosine kinase), and the BCR-ABL fusion gene product is also a tyrosine kinase (Faderl et al., 1999).
The fused BCR-ABL protein interacts with the interleukin-3 p common receptor subunit. The BCR-ABL
transcript is continuously active and does not require activation by other cellular messaging proteins.
In turn, BCR-ABL activates a cascade of proteins which control the cell cycle, speeding up cell division.
Moreover, the BCR-ABL protein inhibits DNA repair, causing genomic instability and making the cell more susceptible to developing further genetic abnormalities, and potentially promoting progression of CML from chronic phase towards untreatable blast crisis. The tyrosine kinase action of the BCR-ABL
protein is believed to be the pathophysiologic cause of chronic myelogenous leukemia. Targeted therapies specifically inhibiting the activity of the BCR-ABL protein have been developed. The first of these was imatinib (marketed as its mesylate salt under the trade name Glivec or Gleevecfl. These and other tyrosine kinase inhibitors can induce complete remissions in CML, confirming the central importance of BCR-ABL in CML (Hehlmann et al., 2007). Limited success was also reported when treating Philadelphia chromosome positive (Ph+) ALL with BCR-ABL inhibitors (Yanada and Naoe, 2006;
Piccaluga et al., 2006).
Despite the fact that introduction of imatinib and second-generation BCR/ABL
inhibitors (e.g. dasatinib) has revolutionized treatment of patients with Philadelphia chromosome positive (Ph+) leukemias, it is a known problem that leukemia cells persist even in successfully treated patients, and some patients develop resistance and ultimately relapse (Swords et al., 2007; Buchert, 2007;
Li and Li, 2007; Kujawski and Talpaz, 2007). The reasons for these drawbacks are not entirely resolved.
Thus, it would be advantageous to have further options to treat patients with Philadelphia chromosome positive leukemia, particularly those patients not responsive to treatment with BCR-ABL
inhibitors.
Summary of the invention It is an object of the application to provide novel therapeutic approaches to treat Philadelphia chromosome positive (Ph+) leukemias. Particularly, it is envisaged to also be able to provide approaches helpful to those patients where BCR-ABL inhibitors, like imatinib, are not (or not anymore) suited as therapy. Surprisingly, it was found that inhibition of placental growth factor (PIGF), even though this factor is not expressed in leukemia cell lines, results in significantly prolonged survival of leukemic mice. Moreover, this prolonged survival is independent of BCR-ABL
mutational status, contrary to what is seen for BCR-ABL inhibitors.
Thus, according to a first aspect, the use of an inhibitor of placental growth factor for the treatment of Philadelphia chromosome positive leukemia is envisaged. Also envisaged is the use of an inhibitor of placental growth factor for the preparation of a medicament for the treatment of Philadelphia chromosome positive leukemia.
Likewise, methods are provided for treating Philadelphia chromosome positive leukemia in a subject in need thereof, comprising administering an inhibitor of PIGF to the subject. Of course, it is the goal to thereby ameliorate the symptoms or ultimately treat the Ph+ leukemia in the subject in need thereof.
According to particular embodiments, the inhibitor of placental growth factor provided in the uses and methods described herein is a selective inhibitor of placental growth factor.
Particularly, the selective inhibitor is an antibody or a fragment thereof specifically binding to placental growth factor. Such antibody may be a monoclonal or polyclonal antibody. According to particular embodiments, the antibody or a fragment thereof specifically binding to placental growth factor is a monoclonal antibody. According to further particular embodiments, it is a murine monoclonal antibody. According to still further particular embodiments, murine monoclonal antibodies may be humanized, i.e.
humanized versions of the mouse monoclonal antibodies made by means of recombinant DNA
technology, starting from the mouse and/or human genomic DNA sequences coding for H and L chains

3

4 or from cDNA clones coding for H and L chains. According to alternative embodiments, the antibody or fragment thereof is a human antibody (or fragment thereof), in particular a human monoclonal antibody.
According to particular embodiments, the fragment of the antibody specifically binding to PIGF is a Fab fragment, a F(ab')2 fragment or a single chain variable fragment (scFv).
According to alternative particular embodiments, the selective inhibitor is a nanobody against PIGF.
According to yet other particular embodiments, the PIGF inhibitor is not a selective inhibitor. A
particular example thereof is a VEGFR-1 inhibitor, such as a VEGFR-1 antibody or a fragment thereof.
Methods and uses of PIGF inhibitors are provided for the treatment of Philadelphia chromosome positive (Ph+) leukemias. According to particular embodiments, the Philadelphia chromosome positive leukemia is chronic myelogenous leukemia (CML). According to alternative embodiments, the Ph+
leukemia is acute lymphoblastic leukemia (ALL), such as e.g. B-ALL (in which B
cells are leukemic cells) or T-ALL (in which the leukemia cells are T cells).
It is envisaged that the methods and uses described herein have broad applicability. In particular, it is envisaged that PIGF inhibitors can be used for treatment (or in methods of treatment) of all Philadelphia chromosome positive leukemias, in particular also those that cannot be treated with a BCR-ABL inhibitor and/or those that cannot be treated with a BCR-ABL inhibitor alone. A Ph+ leukemia may not be treatable with a BCR-ABL inhibitor - or a BCR-ABL inhibitor alone -for a variety of reasons.
The most common reasons are that the leukemia may be (at least partially) insensitive to the treatment (or have developed an at least partial resistance/insensitivity to the treatment), or that the BCR-ABL inhibitor may not be tolerated by the patient (e.g. due to allergy or adverse side effects).
While PIGF inhibition offers a general approach in the treatment of Ph+
leukemias, it may be especially beneficial for those cases where BCR-ABL inhibition, a standard therapeutic approach for e.g. CML, fails to lead to the desired therapeutic effect. The use of PIGF inhibitors may then offer an alternative or additional approach. According to specific embodiments, the PIGF inhibitor may be used in combination with a BCR-ABL inhibitor.
Brief description of the Figures Figure 1 shows PIGF expression in leukemia cells, hematopoietic cells and primary bone marrow stromal cells in vitro. A: amount of secreted PIGF protein by different cell lines and isolated cells (see Example 1 for more details); B: PIGF expression by the hematopoietic fraction (CD45+) and non-hematopoietic fraction (CD45-) of murine BMDSCs. * indicates p<0,001. BM:
bone marrow.

In Figure 2, expression of PIGF and other molecules is shown in vivo (for details, see Example 2). A, B: PIGF protein levels in peripheral blood or bone marrow at different timepoints of leukemic disease progression in mice; C, D: Ratio of PIGF vs. 5VEGFR-1 protein levels in peripheral blood or bone marrow at different timepoints of leukemic disease progression in mice; E:
bone marrow PIGF mRNA
expression in healthy and leukemic mice, * indicates p<0.002; F:
characterization of PIGF expression in subpopulations of bone marrow, * indicates p<0.05; G: bone marrow VEGF mRNA
expression in healthy and leukemic mice; H, I: PIGF protein levels in peripheral blood or bone marrow correlate with leukemic burden in end-staged diseased mice.
Figure 3 demonstrates proliferation of leukemia cells by PIGF (for details, see Example 3). A, B:
expression of Npn-1 and Npn-2 in different leukemia cell lines; C: induction of proliferation in the BV-173 cell line by different concentrations of PIGF; D: induction of proliferation by 50 ng/ml PIGF in a K562 (upper left panel), BV-173 (upper right panel), KCL-22 (lower left panel) and BaF3 (lower right panel) cell line, respectively; E: inhibition of PIGF induced proliferation in the BV-173 cell line by an anti-VEGFR-1 antibody; F: inhibition of PIGF induced proliferation in the BV-173 cell line by an anti-PIGF
antibody. BM: bone marrow; PIGF: placental growth factor; aVEGFR-1: anti-vascular endothelial growth factor receptor-1 antibody; aPIGF: anti-PIGF antibody.
In Figure 4, induction by paracrine interaction between leukemia cells and BMDSCs in vitro is shown (A-D), as well as with leukemia-cell conditioned medium (E). A: PIGF
expression in BDMSCs, in the BV-173 cell line and in co-culture (BMDSCs + BV); B: PIGF expression in S17 cells, in the BV-173 cell line and in co-culture; C: proliferation of BV-173 leukemia cells alone and in co-culture with BMDSCs, and inhibition by an anti-PIGF antibody; D: proliferation of BMDSCs alone and in co-culture with BV-173 leukemia cells, and inhibition by an anti-PIGF antibody; E: PIGF
upregulation in S17 cells by incubation with a leukemia cell (BV-173) conditioned medium. BV: BV-173 cell line; aPIGF: anti-PIGF
antibody.
Figure 5A: survival of leukemic PIGF-/- and WT mice; B: survival of cross-over leukemic mice (for details, see Example 5); C: survival of mice bearing leukemia induced by lymphatic BCR-ABL+ BaF3 cells, either treated with an anti-PIGF antibody or a control antibody; D, E: FACS
analysis of BCR-ABL+ cells at early stage (d15) and end-stage (d28) leukemia and effect of inhibition with anti-PIGF antibody; F: bone marrow histology of control and anti-PIGF treated end-stage leukemic mice; G:
Survival in a mouse model of imatinib-sensitive CML, either treated with an anti-PIGF antibody or a control antibody; H:
Survival in a mouse model of imatinib-resistant CML, either treated with an anti-PIGF antibody or a control antibody. aPIGF: anti-PIGF antibody; d: days; T315I: the T315I
mutation of the BCR-ABL fusion protein. For more details, see Example 6.

5 Figure 6 shows the inhibition of bone marrow hypervascularization and fibrosis upon anti-PIGF
treatment (see Example 7). A, C: bone marrow vascular density (MVD) in mock-transplanted, control antibody-treated and anti-PIGF treated mice with end-stage leukemia; B, D:
length of reticulin+ fibers and bone marrow fibrosis in mock-transplanted, control antibody-treated and anti-PIGF treated mice .. with end-stage leukemia.
In Figure 7, data on PIGF expression in human CML are shown (A-D, Example 8) as well as data correlating PIGF expression and imatinib treatment in mice (E) and humans (F, Example 9). A: plasma PIGF levels in different stages of CML (healthy controls, chronic phase and blast crisis), * indicates p<0.0001; B: bone marrow plasma PIGF levels in CML patients; C: correlation between PIGF levels and BCR/ABL transcript numbers in human CML; D: QRT-PCR of PIGF expression in healthy controls, leukemia cells and stromal cells of CML patients; E: bone marrow PIGF levels of untreated leukemic mice and healthy and leukemic mice treated with imatinib; F: PIGF levels in healthy human subjects and patients with different response levels to imatinib (IM). For details, see Example 9.
Detailed description Definitions The present invention will be described with respect to particular embodiments and with reference to certain drawings but the invention is not limited thereto but only by the claims. Any reference signs in the claims shall not be construed as limiting the scope. The drawings described are only schematic and are non-limiting. In the drawings, the size of some of the elements may be exaggerated and not drawn on scale for illustrative purposes. Where the term "comprising" is used in the present description and claims, it does not exclude other elements or steps. Where an indefinite or definite article is used when referring to a singular noun e.g. "a" or "an", "the", this includes a plural of that noun unless something .. else is specifically stated.
Furthermore, the terms first, second, third and the like in the description and in the claims, are used for distinguishing between similar elements and not necessarily for describing a sequential or chronological order. It is to be understood that the terms so used are interchangeable under appropriate circumstances and that the embodiments of the invention described herein are capable of operation in other sequences than described or illustrated herein.
The following terms or definitions are provided solely to aid in the understanding of the invention.
Unless specifically defined herein, all terms used herein have the same meaning as they would to one skilled in the art of the present invention. Practitioners are particularly directed to Sambrook et al.,

6 Molecular Cloning: A Laboratory Manual, 2nd ed., Cold Spring Harbor Press, Plainsview, New York (1989); and Ausubel et al., Current Protocols in Molecular Biology (Supplement 47), John Wiley & Sons, New York (1999), for definitions and terms of the art. The definitions provided herein should not be construed to have a scope less than understood by a person of ordinary skill in the art.
"Placental growth factor" or "PIGF" as used herein refers to a member of the VEGF (vascular endothelial growth factor) sub-family, in particular the human PIGF (GenelD
5228; RefSeqs (independently of genome builds) NM_002632.4 (mRNA) and NP_002623.2 (protein)). Unless otherwise specified, the term "PIGF" may refer to the gene as well as its products, such as the PIGF
RNA (most particularly, the PIGF mRNA) and the PIGF protein. All isoforms of PIGF are intended to be included in the definition of PIGF.
The term "Philadelphia chromosome positive" or "Ph+" leukemia as used herein refers to diseases wherein the Philadelphia translocation is confirmed to be present. The Philadelphia chromosome is a result of the t(9;22)(q34;q11) translocation (Philadelphia translocation). At least two alternative forms of the Philadelphia chromosome translocation are documented, but both alternative breakpoints result in the joining of different exon sets of BCR (OMIM *151410) on chromosome 22 to a common subset of the exons of the ABL gene (OMIM *189980) located on chromosome 9.
Thus, the fusion may results in 2 alternative chimeric oncogene products called p210(BCR-ABL) and p185(BCR-ABL), herein collectively referred to as "BCR-ABL" (included in OMIM *151410 and *189980).
The activation of ABL
tyrosine kinase activity is necessary for the oncogenic potential of the chimeric oncogene. As the presence of the chimeric BCR-ABL gene (and its gene products) is a hallmark of Ph+ leukemias, "Ph+"
may also be referred to as "BCR-ABL positive" or "BCR-ABL+" leukemias, to indicate the presence of the fusion gene. Note that translocations or mutations which result in the generation of a functional BCR-ABL chimeric gene (i.e. BCR-ABL+) will herein thus also be classified as "Ph+", regardless of the mechanism of the translocation. This may for instance be the case with more complex translocations.
A "selective inhibitor of placental growth factor" as used in the application is a molecule or compound that inhibits the function or signaling pathway of PIGF without interfering with the physiological function of other molecules. In particular, a selective PIGF inhibitor will not interfere with the function of VEGF. Thus, as a non-limiting example, a compound specifically directed against PIGF (e.g. an anti-PIGF antibody) is a selective inhibitor, while compounds that also target VEGF
(such as VEGFR1-based compounds) or target VEGF/PIGF-shared receptors (e.g. an antibody against VEGFR1, or 5VEGFR-1) is typically a non-selective inhibitor.

7 "Chronic myelogenous leukemia", "chronic myeloid leukemia" or "CML" as used herein refers to a clonal myeloproliferative disorder of a pluripotent stem cell with a specific cytogenetic abnormality (the Philadelphia chromosome), involving myeloid, erythroid, megakaryocytic, B
lymphoid, and sometimes T lymphoid cells, but not marrow fibroblasts (OMIM #608232; Silver, 2003).
"Acute lymphocytic leukemia", "acute lymphoblastic leukemia" or "ALL" as used in the application refers to an acute form of leukemia in which immature white blood cells continuously multiply and are overproduced in the bone marrow. Examples of ALL include T-ALL and B-ALL. A
particular subset of the heterogeneous group of ALL cases also is positive for the Philadelphia chromosome, i.e. Ph+ or BCR-ABL+ (Radich, 2001; Alvarado et al., 2007).
As used in the application, a "BCR-ABL inhibitor" is a molecule or compound that inhibits the expression or function of the chimeric BCR-ABL gene or its gene product. Of note, the BCR-ABL
inhibitor need not necessarily be specific for BCR-ABL. For instance, it may be a tyrosine kinase inhibitor which targets more than just the BCR-ABL tyrosine kinase. A BCR-ABL
inhibitor is well-known as a targeted therapy in Ph+ leukemia, a non-limiting but typical example is imatinib. Other examples are included in the application.
"Treating" as used in the application means to achieve a significant amelioration of one or more clinical symptoms associated with Ph+ leukemia. Depending on the situation, the significant amelioration may be scored quantitatively or qualitatively. Qualitative criteria may e.g. be patient well-being. In the case of quantitative evaluation, the significant amelioration is typically a more than 10%, more than 20%, more than 25%, more than 30%, more than 40%, more than 50%, more than 60%, more than 70%, more than 75%, more than 80%, more than 90%, more than 95%, or a 100% or more improvement over the situation prior to administration of the PIGF inhibitor. Of course, if improvement is expressed as a decrease (e.g. the number of malignant cells present in a patient sample), improvement cannot be more than 100%. The time-frame over which the improvement is evaluated will depend on the type of criteria observed and can be determined by the person skilled in the art.
It is an important aspect of the invention to provide methods and uses of inhibitors of placental growth factor for the treatment of Philadelphia chromosome positive leukemia. Also, the use of inhibitors of placental growth factor for the manufacture of a medicament for the treatment of Philadelphia chromosome positive leukemia is taught.
Inhibitors of placental growth factor (PIGF) particularly are selective inhibitors of PIGF, so as not to interfere with other molecules. In particular, the selective PIGF inhibitors should not interfere with the function of VEGF. According to particular embodiments, the PIGF inhibitor is not a VEGF inhibitor.

8 According to alternative particular embodiments, the PIGF inhibitor is not a VEGFR1 inhibitor.
According to specific embodiments, the PIGF inhibitor is not based on the VEGFR1.
Inhibitors may neutralize the activity of PIGF by interfering with its synthesis, translation, dimerisation, receptor-binding and/or receptor-binding-mediated signal transduction.
Neutralizing the activity of PIGF should be understood as suppressing the PIGF activity for at least 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or even 100%.
Inhibitors, in particular selective inhibitors, of PIGF are known in the art.
According to particular embodiments, the selective inhibitors are antibodies. The term "antibody" or "antibodies" relates to an antibody characterized as being specifically directed against PIGF or any functional derivative thereof or an antigen-binding fragment thereof, particularly of the F (ab') 2, F (ab) or single chain Fy (scFv) type, or any type of recombinant antibody derived thereof. The anti-PIGF antibodies described herein, including specific polyclonal antisera prepared against PIGF or any functional derivative thereof, have no cross-reactivity to others proteins. According to particular embodiments, the anti-PIGF
antibodies are monoclonal antibodies. The monoclonal antibodies can for instance be produced by any hybridoma liable to be formed according to classical methods from splenic cells of an animal, particularly of a mouse or rat immunized against PIGF or any functional derivative thereof, and of cells of a myeloma cell line, and to be selected by the ability of the hybridoma to produce the monoclonal antibodies recognizing PIGF or any functional derivative thereof which have been initially used for the immunization of the animals.
According to particular embodiments, preparing monoclonal antibodies against human PIGF can for instance be done as follows: a recombinant human PIGF fusion protein, consisting of the amino acids encoded by PIGF or a fragment thereof is coupled to Glutathione S-transferase (GST) and expressed in Escherichia coli and purified by affinity chromatography on immobilised glutathione (Amersham Biosciences). Recombinant human PIGF is also obtainable from R&D Systems Inc.
614 McKinley Place N.
E. Minneapolis, MN 55413, USA. (264-PG-010, 264-PG-010/CF, 264-PG-050 or 264-PG-050/CF), from Research Diagnostics Inc, Pleasant Hill Road, Flanders NJ 07836, USA
(Recombinant Human PIGF-1 :
Cat#RDI-300-015 & Cat#RDI-300-016 and Recombinant Human PIGF-2: Cat#RDI-300-019) or from ALEXIS Corporation, CH-4415 Lausanne, Switzerland (Placenta Growth Factor-2 (human) (recombinant) cat#RLT-300-020).
Recombinant human PLGF is mixed with an equal amount of an adjuvant, and an obtained mixture is then subcutaneously administrated to Balb/c male mice (8 weeks old upon the start of immunisation) in an amount corresponding to an amount of PIGF of 100 lig per 1 mouse (priming immunisation).

9 After about 21 days, immunisation can be performed by subcutaneous administration in the same manner as described above (booster immunisation). After 19 days or 30 days from the booster, the mice can administrated through their tail veins with 200 ul of a preparation obtained by diluting human PIGF with PBS (phosphate-buffered physiological saline) to have a concentration of 250 ug/m1 .. (final immunisation). Spleens have then to be excised from the mice after about 3 days from the final immunisation, and they have to be separated into single cells. Subsequently, the spleen cells should be washed with a proper medium, e.g. DMEM medium. On the other hand, suitable mouse myeloma cells (e. g. 5p2/0- Ag14) have to be collected in the logarithmic growth phase, and to be washed with a proper medium, e.g. DMEM medium. The spleen cells and the mouse myeloma cells have to be sufficiently mixed in a plastic tube in a ratio of numbers of the cells of 10:
1, followed by addition of 50% (w/v) polyethylene glycol (PEG e.g. of Boehringer Mannheim, average molecular weight: 4000) to perform cell fusion at 37 C for 7 minutes. After removal of the supernatant solution (by means of centrifugation), the residue is added with HAT medium (DMEM medium containing

10% fetal bovine serum added with hypoxanthine, aminopterin, and thymidine). The residue has to be suspended so .. that a concentration of the spleen cells of about 5x106 cells/ml is obtained. This cell suspension can then be dispensed and poured into 96-well plastic plates so that one well contains about 100 ul of the suspension, followed by cultivation at 37 C in 5% carbon dioxide. HAT medium has to be supplemented; for instance in an amount of 50 ul/well on 2nd and 5th days.
After that, half volume of the medium can be exchanged every 3 or 4 days in conformity with proliferation of hybridomas.
Hybridomas, which produce the monoclonal antibody of the present invention, have to be screened for. This has to be done by using, as an index, the inhibitory activity of the monoclonal antibody on the physiological activity possessed by PIGF.
Hybridomas which produced monoclonal antibodies exhibiting reactivity with PIGF have then to be selected from the selected clones. The obtained hybridomas have then to be transferred to a suitable medium for instance HT medium which is the same as HAT medium, but without aminopterin, and cultured further. Cloning can be performed twice in accordance with the limiting dilution method by which stable hybridomas are obtainable.
Production and purification of monoclonal antibodies may then be done as follows: 2.6, 10, 14-Tetramethylpentadecane (e. g. Pristane of Sigma, 0.5 ml) can be intraperitoneally injected into Balb/c female mice (6 to 8 weeks old from the birth). After 10 to 20 days, cells of clones (1X106 to 107 cells) can be suspended in PBS and intraperitoneally inoculated into the mice. After 7 to 10 days, the mice can be sacrificed and subjected to an abdominal operation, from which produced ascitic fluid can be collected. The ascitic fluid can be centrifuged to remove insoluble matters, and a supernatant was recovered and stored at-20 C until purification. Consequently, IgG can be purified from the ascitic fluid supernatant described above by using Hi-Trap Protein-A antibody purification kit (available from Pharmacia, Roosendaal, Netherlands). Namely, the ascitic fluid (2 ml) can be added with Solution A (1.5 M glycine, 3 M NaCI, pH 8.9, 8 ml), and filtrated with a filter for filtration having a pore size of 45 Im (Millipore). After that, an obtained filtrate can applied to a column (column volume: 1 ml) charged with Protein Sepharose HP (produced by Pharmacia) sufficiently equilibrated with Solution A, and the column has be washed with Solution A in an amount of 10-fold column volume.
Subsequently, an IgG
fraction can be eluted with Solution B (0.1 M glycine, pH 2.8) in an amount of 10-fold column volume.
The eluted IgG fraction can be dialysed against PBS. The monoclonal antibodies can be determined for their IgG subclasses by using the purified antibodies obtained in the foregoing, by means of a commercially available subclass-determining kit (trade name: Mono Ab-ID [IA
Kit A, produced by Zymed). This method is based on the [LISA method.
The inhibitory activities of monoclonal antibodies can be tested for complete inhibition of binding of rPIGF to its VEGFR1 receptor. This can for instance be measured in an immunofunctional [LISA in which 96-well plates are coated with 100 ul of 1 ug/m1 of rmFlt-I/Fc chimera overnight at room temperature in PBS. After blocking for 1 hour with 1 % BSA in PBS, 100 ul of a mixture of 70 ul of hybridoma medium pre-incubated with 70 ul of recombinant mPIGF-2 at 10 ng/ml for 2 hours at room temperature is then applied to the plate. A standard of rmPIGF-2 ranging from 20 ng/ml to 156 pg/ml can be included (diluted in PBS- Tween. BSA-EDTA). Plates can then be incubated 1 hour at 37 C
and 1 hour at room temperature, washed 5 times with PBS-Tween and 100 ul of biotinylated goat anti-murine PIGF-2 at 200 ng/ml can be applied for 2 hours at room temperature. After washing 5 times with PBS-Tween, 100 ul of avidin-HRP conjugate (Vectastorin ABC kit) can be applied for 1 hour at room temperature. After washing 5 times with PBS-Tween, the plate can be developed with 90 ul of o-phenylene diamine in citrate phosphate buffer pH 5.0 for 30 minutes and measured at 490 nm.
Also provided herein are inhibiting antibody ligands, which are able to bind to PIGF. More preferably, such a ligand should be able to recognise a specific epitope located on PIGF.
For instance, the present invention relates to ligands of the above-mentioned type, being derived from a monoclonal antibody produced by on purpose immunisation in animals. The present invention also provides an antigen-binding Fab fragment, or a homologue derivative of such fragment, which may be obtained by proteolytic digestion of the said monoclonal antibody by papain, using methods well known in the art.
In order to reduce the immunogenicity of the murine anti-PIGF monoclonal antibody, the present invention also includes the construction of a chimeric antibody, preferentially as a single-chain variable

11 domain, which combines the variable region of the mouse antibody with a human antibody constant region - a so-called humanised monoclonal antibody.
The monoclonal antibodies produced in animals may be humanised, for instance by associating the binding complementarily determining region ("CDR") from the non-human monoclonal antibody with human framework regions - in particular the constant C region of human gene -such as disclosed by Jones et al. (Jones et al., 1986) or Riechmann (Riechmann et al., 1988), or otherwise hybridised.
The monoclonal antibodies according to these embodiments may be humanized versions of the mouse monoclonal antibodies made by means of recombinant DNA technology, departing from the mouse and/or human genomic DNA sequences coding for H and L chains or from cDNA
clones coding for H
and L chains.
Alternatively the monoclonal antibodies according to these embodiments may be human monoclonal antibodies. Such human monoclonal antibodies are prepared, for instance, by means of human peripheral blood lymphocytes (PBL) repopulation of severe combined immune deficiency (SCID) mice as described in PCT/EP99/03605 or by using transgenic non-human animals capable of producing human antibodies as described in US patent 5,545,806. Also fragments derived from these monoclonal antibodies such as Fab, F (a b')2 and scFy ("single chain variable fragment"), providing they have retained the original binding properties, form part of what is disclosed herein. Such fragments are commonly generated by, for instance, enzymatic digestion of the antibodies with papain, pepsin, or other proteases. According to particular embodiments, the selective inhibitor of PIGF is a fragment of an antibody, which fragment specifically binds to placental growth factor.
According to particular embodiments, the antibody fragment is a Fab fragment, a F(ab')2 fragment or a single chain variable fragment (scFv).
According to specific embodiments, preparing of F (ab') 2 or monovalent Fab fragments is for instance as follows: in order to prepare F (ab') 2 fragments, the monoclonal antibody can be dialysed overnight against a 0.1 mol/L citrate buffer (pH 3.5). The antibody (200 parts) is then digested by incubation with pepsin (1 part) available from Sigma (Saint-Louis, Missouri) for 1 hour at 37 C. Digestion is consequently stopped by adding 1 volume of a 1 M Tris HCI buffer (pH 9) to 10 volumes of antibody.
Monovalent Fab fragments can be prepared by papain digestion as follows: a 1 volume of a 1M
phosphate buffer (pH 7.3) is added to 10 volumes of the monoclonal antibody, then 1 volume papain (Sigma) is added to 25 volumes of the phosphate buffer containing monoclonal antibody, 10 mmo1/1 L-Cysteine HCI (Sigma) and 15 mmo1/1 ethylene diaminetetra-acetic acid (hereinafter referred to as EDTA). After incubation for 3 hours at 37 C, digestion is stopped by adding a final concentration of 30

12 WO 2010/037864 PCT/11'2009/062861 nnmo1/1 freshly prepared iodoacetamide solution (Sigma), keeping the mixture in the dark at room temperature for 30 minutes. Both F (ab') 2 and Fab fragments can further be purified from contaminating intact IgG and Fc fragments using protein-A-Sepharose. The purified fragments can finally dialysed against phosphate-buffered saline (herein after referred as PBS). Purity of the .. fragments can be determined by sodiumdodecylsulphate polyacrylamide gel electrophoresis and the protein concentration can be measured using the bicinchonicic acid Protein Assay Reagent A (Pierce, Rockford, Illinois).
It is well known to the person skilled in the art that (monoclonal) antibodies, or fragments thereof, can be modified for various uses. The antibodies involved in the invention can be labeled by an appropriate label of the enzymatic, fluorescent, or radioactive type.
Examples of anti-PIGF antibodies are well documented in the art. They include, but are not limited to the one described by Fischer (Fischer et al., 2007), or the nnurine monoclonal antibody Mab-PL5D11 (W001/85796; this monoclonal antibody is available in the VIB Vesalius Research Center, UZ
Gasthuisberg, Herestraat 49, B-3000 Leuven). Other antibodies, such as the 16D3 antibody, are for instance described in EP1869085. Also W02004/002524 describes how to generate anti-PIGF
antibodies.
Moreover, anti-PIGF antibodies are also commercially available, e.g. from Santa Cruz Biotechnology Inc, Abcam, Novus biologicals, R&D systems, Sigma-Aldrich and many more companies.
It is to be understood that the above methods also apply for the generation of other antibodies, e.g.
for the generation of anti-VEGFR-1 antibodies, which are non-selective inhibitors of PIGF.
Other inhibitors of PIGF, particularly selectively inhibitors of PIGF, include, but are not limited to, peptides, tetrameric peptides, proteins, organic molecules, or fragments or homologues thereof having neutralizing effect as stated above. Further inhibitors in this non-exhaustive list are anti-sense RNA and DNA molecules and ribozymes that function to inhibit the translation of PIGF, peptide aptamers (e.g., siRNAs (e.g. Santa Cruz Biotechnology Inc), hairpin RNAs or shRNAs (e.g. Santa Cruz Biotechnology Inc), morfolinos, nanobodies and small molecules. Many of such (selective as well as non-selective) inhibitors are commercially available. Some of the possible inhibitors will be further discussed here.
Small molecules, e. g. small organic molecules, and other drug candidates can be obtained, for example, from combinatorial and natural product libraries. To screen for said candidate/test .. molecules, for instance cell lines that express VEGFR-1 may be used and the signal transduction is monitored as described in detail in WO 01/85796.

13 Said monitoring can be measured using standard biochemical techniques. Other responses such as activation or suppression of catalytic activity, phosphorylation (e. g. the tyrosine phosphorylation of the intracellular domain of the receptor) or dephosphorylation of other proteins, activation or modulation of second messenger production, changes in cellular ion levels, association, dissociation or translocation of signaling molecules, or transcription or translation of specific genes may also be monitored. These assays may be performed using conventional techniques developed for these purposes in the course of screening. Inhibition of ligand binding to its cellular receptor may, via signal transduction pathways, affect a variety of cellular processes. Cellular processes under the control of the VEGFR-1/PIGF signalling pathway may include, but are not limited to, normal cellular functions, proliferation, differentiation, maintenance of cell shape, and adhesion, in addition to abnormal or potentially deleterious processes such as unregulated cell proliferation, loss of contact inhibition, blocking of differentiation or cell death. The qualitative or quantitative observation and measurement of any of the described cellular processes by techniques known in the art may be advantageously used as a means of scoring for signal transduction in the course of screening.
An alternative way of screening for small molecules is via in silico design.
The crystal structure of human Placental growth factor is available (PDB Code: 1FZV), so this may also serve as a platform for further small molecule antagonist screens. An inhibitory molecule or series of molecules can be designed based on the structure of PIGF, after which they can be validated using screens as described above.
Random peptide libraries, such as tetrameric peptide libraries further described herein, consisting of all possible combinations of amino acids attached to a solid phase support may be used to identify peptides that are able to bind to the ligand binding site of a given receptor or other functional domains of a receptor such as kinase domains (Lam et al., 1991). The screening of peptide libraries may have therapeutic value in the discovery of pharmaceutical agents that act to inhibit the biological activity of receptors through their interactions with the given receptor. Identification of molecules that are able to bind to PIGF (or optionally the VEGFR-1) may be accomplished by screening a peptide library with recombinant PIGF protein (or soluble VEGFR-1 protein). For example, the kinase and extracellular ligand binding domains of VEGFR-1 may be separately expressed and used to screen peptide libraries.
In addition to using soluble VEGFR-1 molecules, in another embodiment, it is possible to detect peptides that bind to cell surface receptors using intact cells. The cells used in this technique may be either alive or fixed cells. The cells will be incubated with the random peptide library and will bind certain peptides in the library to form a "rosette" between the target cells and the relevant solid phase

14 support/peptide. The rosette can thereafter be isolated by differential centrifugation or removed physically under a dissecting microscope.
In a specific embodiment transdominant-negative mutant forms of VEGF-receptors (e.g. a transdominant-negative receptor of VEGF-R1) can be used to inhibit the signal transduction of PIGF.
The use of said transdominant-negative mutant forms of VEGF-receptors is fully described in US patent 5,851,999. Moreover, the placenta soluble fms-like tyrosine kinase 1 (sFlt1), a splice variant of the VEGF receptor Fit1 lacking the transmembrane and cytoplasmic domains, is known to act as a potent PIGF antagonist (Kendall et al., 1996; Shibuya, 2001) and soluble VEGFR1 fusion proteins (Aiello et al., 1995) can be used in vivo to inhibit PIGF activity. However, although successful in its own right, the use of transdominant-negative receptors may have the drawback of not being selective inhibitors of PIGF
alone. Thus, according to specific embodiments, the inhibitor of PIGF is not a transdominant-negative receptor.
RNA has distinct advantages over small organic molecules when considering its use to inactivate protein function in vivo. An RNA encoding sequence can be linked to a promoter and this artificial gene can be introduced into cells or organisms. Depending on the regulatory sequence included, this provides a unique way of constructing a time- and/or tissue-specific suppressor gene. Such RNA
expressing genes are usually smaller than protein-coding genes and can be inserted easily into gene therapy vectors. Unlike a foreign or altered protein, RNA is less likely to evoke an immune response.
Antisense molecules and ribozymes have been developed as "code blockers" to inactivate gene function, with their promise of rational drug design and exquisite specificity (Altman, 1995; Matteucci and Wagner, 1996). Mechanistically, both antisense oligodeoxynucleotides ("ODNs") and bioengineered ribozymes are expected to achieve specific binding in the first step of their action by forming a stable duplex (or triplex in some cases of the ODNs) with a target nucleotide sequence based on Watson-Crick or Hoogsteen base pairing.
In certain embodiments, a PIGF inhibitor may be an aptamer. Methods of constructing and determining the binding characteristics of aptanners are well known in the art. For example, such techniques are described in U.S. Pat. Nos. 5,582,981, 5,595,877 and 5,637,459.
Aptamers may be prepared by any known method, including synthetic, recombinant, and purification methods, and may be used alone or in combination with other ligands specific for the same target in general, a minimum of approximately 3 nucleotides, preferably at least 5 nucleotides, are necessary to effect specific binding. Aptamers of sequences shorter than 10 bases may be feasible, although aptamers of 10, 20, 30 or 40 nucleotides may be preferred.

Aptamers need to contain the sequence that confers binding specificity, but may be extended with flanking regions and otherwise derivatized. In particular embodiments, the PIGF-binding sequences of aptamers may be flanked by primer-binding sequences, facilitating the amplification of the aptamers by PCR or other amplification techniques. In a further embodiment, the flanking sequence may comprise a specific sequence that preferentially recognizes or binds a moiety to enhance the immobilization of the aptamer to a substrate.
Aptamers may be isolated, sequenced, and/or amplified or synthesized as conventional DNA or RNA
molecules. Alternatively, aptamers of interest may comprise modified oligomers. Any of the hydroxyl groups ordinarily present in aptamers may be replaced by phosphonate groups, phosphate groups, protected by a standard protecting group, or activated to prepare additional linkages to other nucleotides, or may be conjugated to solid supports. One or more phosphodiester linkages may be replaced by alternative linking groups, such as P(0)0 replaced by P(0)S, P(0)NR 2, P(0)R, P(0)OR', CO, or CNR 2 , wherein R is H or alkyl (1-20 C) and R' is alkyl (1-20 C); in addition, this group may be attached to adjacent nucleotides through 0 or S. Not all linkages in an oligomer need to be identical.
The aptamers used as starting materials to determine specific binding sequences may be single-stranded or double-stranded DNA or RNA. In a particular embodiment, the sequences are single-stranded DNA, which is less susceptible to nuclease degradation than RNA.
According to particular embodiments, the starting aptamer will contain a randomized sequence portion, generally including from about 10 to 400 nucleotides, particularly from 20 to 100 nucleotides. The randomized sequence is flanked by primer sequences that permit the amplification of aptamers found to bind to the target. For synthesis of the randomized regions, mixtures of nucleotides at the positions where randomization is desired may be added during synthesis.
Methods for preparation and screening of aptamers that bind to particular targets of interest are well known, for example U.S. Pat. No. 5,475,096 and U.S. Pat. No. 5,270,163, The technique generally involves selection from a mixture of candidate aptamers and step-wise iterations of binding, separation of bound from unbound aptamers and amplification. Because only a small number of sequences (possibly only one molecule of aptamer) corresponding to the highest affinity aptamers exist in the mixture, it is generally desirable to set the partitioning criteria so that a significant amount of aptamers in the mixture (approximately 5-50%) are retained during separation. Each cycle results in an enrichment of aptamers with high affinity for the target. Repetition for between three to six selection and amplification cycles may be used to generate aptamers that bind with high affinity and specificity to the target, such as PIGF.
According to particular embodiments, the aptamers are RNA aptamers which specifically interact with PLGF, or optionally with VEGF-R1 or other non nucleic acid substances of the VEGFR-1/PIGF signalling pathway. These can be used as therapeutic reagents. RNA aptamers are used for their ability directly to disrupt protein function. Selection of aptamers in vitro allows rapid isolation of extremely rare RNAs that have high specificity and affinity for specific proteins. Exemplary RNA
aptamers are described in U.S. Pat. No. 5,270,163 to Gold et al., and papers by Ellington and Szostak, 1990, and Tuerk and Gold, 1990. Unlike antisense compounds, whose targets are one dimensional lattices, RNA aptamers can bind to the three dimensional surfaces of a protein. Moreover, RNA aptamers can frequently discriminate finely among discrete functional sites of a protein (Gold et al., 1995). As therapeutic reagents, aptamers not only have the combined advantages of antibodies and small molecular mass drugs, but in vivo production of RNA aptamers also can be controlled genetically. The controlled expression of high affinity RNA aptamers offers a means of rapidly inactivating specific domains of proteins and thereby assessing their function and mechanism of action.
Toole et al in U.S. Pat. No. 5,840,867 and Grossman et al in U.S. Pat. No.
6,207,388 disclose methods for making aptamers and aptamers that bind to biomolecules. These aptamers can be used to interfere with the normal biological function of the biomolecules, as a separation tool, a diagnostic or a therapeutic. The aptamers described by Toole et al. can be single chain or duplex RNA or DNA.
.. Korth et al. (Korth et al., 1997) have applied single-stranded RNA aptamers directed against Syrian golden hamster prion protein and the aptamers were able to recognise their specific target within a mixture of hundreds of different proteins. Davis (1994) described single-stranded DNA aptamer that binds the active site of thrombin and exhibits anti-coagulation effects in vivo.
Rajendran, Manjula et al. (U520020127581) provide methods for the in vitro selection of signaling aptamers comprising the steps of synthesising a DNA pool, the DNA having a random insert of nucleotides of a specific skewed mole ratio; amplifying the DNA pool;
transcribing an RNA pool from the amplified DNA using a fluorescently labelled nucleotide; applying the fluorescently labelled RNA
pool to an affinity column to remove the high-affinity fluorescent RNA
molecules from the fluorescently labelled RNA pool; obtaining a cDNA pool from the high-affinity fluorescent RNA
.. molecules; repeating the amplification and selection steps on the fluorescent RNA molecules and cloning the fluorescent RNA molecules to yield signaling aptamers. Signaling aptamers comprising DNA
molecules are also selected for.

Also provided herein is a signaling aptamer that transduces the conformational change upon binding a ligand to a change in fluorescence intensity of the signaling aptamer.
Aptamers can thus be designed to interact specifically with non-nucleic acid substances, such as PIGF
or VEGFR1. Aptamers can function as high affinity receptors for PIGF or can tightly interact with PIGF
(or optionally VEGFR1). The folding of an initially unstructured molecule around PLGF or VEGFR1 and forming a hydrogen-bond network with PLGF or VEGFR1 facilitate this neutralising binding.
Aptamers can however also be catalytic. Aptamers that are catalytic are considered approximate ribozymes, or aptazymes. Aptamers can as well be designed to interact specifically with nucleic acid substances, other than to simply bind them on the basis of Watson-Crick base pairing between bases in nucleic acid sequences of opposite orientation.
Such aptamers, if catalytic, may be fairly called aptazymes. Such specific action can be sought for therapeutic purposes.
The production of 2'-Fluoropyrimidine RNA-based aptamers to the 165-amino acid form of vascular endothelial growth factor (VEGF165), a protein with 53% sequence homology to PIGF, have been described in detail by Ruckman et al., 1998 and Bridonneau et al., 1999. Using the SELEX process (described above, US patent by Gold et al.) 2'-F-pyrimidine RNA
oligonucleotide ligands (aptamers) to human VEGF165 were isolated. These aptamers also bound to the heterodimers of VEGF165 and PIGF123 and likely also to larger isoforms such as the isoform PIGF152.
Representative aptamers from three distinct sequence families were truncated to the minimal sequence capable of high affinity binding to VEGF (23-29 nucleotides) and were further modified by replacement of 2'-0-methyl for 2'-OH at all ribopurine positions where the substitution was tolerated. This protocol can be used by a man skilled in the art to manufacture neutralising anti-PIGF aptamers. A VEGF
aptamer (Macugen , pegaptanib sodium) is also the first therapeutic aptamer to be administered to humans and is currently being marketed for patients with age-related macular degeneration.
Also within the scope of inhibitors as described herein are oligoribonucleotide sequences, that include catalysing RNA molecules such as ribozymes that function to inhibit the translation of VEGFR-1 mRNA
or PIGF mRNA.
A number of RNA molecules are known to be active as catalysts and do not merely serve as the means by which information is moved out of the nucleus.
Ribozymes are enzymatic RNA molecules capable of catalysing the specific cleavage of RNA. The mechanism of ribozyme action involves sequence specific hybridisation of the ribozyme molecule to complementary target RNA, followed by an endonucleolytic cleavage. The activity of self-cleaving or cleaving other RNA of ribozymes is understood to be dependent on the RNA's secondary structure, which can be dependent on factors such as base sequence and the inclusion of metal locations.
Ribozymes have great utility in artificially controlling gene expression.
Advantage can be taken of the very specific charge patterns of nucleic acids, their bases and backbones and DNA's ability to form predictable secondary structure, based upon base sequence and predictable Watson-Crick base pairing. The small dimensions and flexible nature of nucleic acid make it well suited for constructing complexes capable of recognising and specifically binding to features on other substances, such as proteins. Through SELEX-driven screening (U. S. Pat. No. 5,567, 588 to Gold et al.), which depends upon binding to single-stranded nucleic acids mounted on biochips, researchers have discovered ribozymes, which are 100- or even 1000-fold more active catalytically. Fernandez et al.
(2001) report data collected from a single molecule conformational change in a ribozyme.
Fernandez et al. also report that such essentially duplex nucleic acid structures undergo "all or none" discrete transitions in conformation, not the progressive pair by pair binding one would expect.
A circular RNA that has enzymatic activity to cleave a separate RNA molecule at a cleavage site and RNA molecules capable of conferring stability to RNA in vivo through an endogenous ribozyme binding protein is described in U.S. Pat. No. 5,712,128 of Been et al. and U.S. Pat.
No. 5,985,620 of Sioud.
Specific ribozyme cleavage sites within any potential RNA target are initially identified by scanning the target molecule for ribozyme cleavage sites, which include the following sequences, GUA, GUU and GUC. Once identified, short RNA sequences of between 15 and 20 ribonucleotides corresponding to the region of the target gene containing the cleavage site may be evaluated for predicted structural features such as secondary structure that may render the oligonucleotide sequence unsuitable. The suitability of candidate targets may also be evaluated by testing their accessibility to hybridisation with complementary oligonucleotides, using ribonuclease protection assays.
Another way of providing inhibition is the use of engineered hammerhead motif ribozyme molecules that specifically and efficiently catalyse endonucleolytic cleavage of PIGF
(or optionally VEGFR-1) RNA
sequences for the treatment of Philadelphia chromosome positive leukemia in a subject, preferably a mammalian and yet more preferably a human. Anti-VEGFR-1-ribozyme, such as Angiozyme, which has been developed against VEGFR-1 mRNA by Ribozyme Pharmaceuticals Inc, Boulder, Colorado 80301, USA have already been used in cancer therapy (Weng and Usman, 2001; Pavco et al., 2000). This Angiozyme, among other anti-VEGFR-1 catalytic RNA molecules can be used for the inhibition of the PIGF receptor activity, which downregulate PIGF receptor function by specifically cleaving the mRNAs for the primary PIGF receptors, VEGFR-1. Clinical trials of an anti-VEGFR-1 ribozyme are currently in progress for breast cancer.
Other inhibitors envisaged herein are oligoribonucleotide sequences, that include anti-sense RNA and DNA molecules and siRNA constructs which are homologous to a part of the mRNA
sequence of the PIGF gene or its receptor VEGFR-1 mRNA. RNA interference or "RNAi" is a term initially coined by Fire and co-workers to describe the observation that double-stranded RNA (dsRNA) can block gene expression (Fire et al., 1998). dsRNA directs gene-specific, post-transcriptional silencing in many organisms, including vertebrates, and has provided a new tool for studying gene function. RNAi involves mRNA degradation. PIGF can be silenced by a method of selective post-transcriptional silencing of the expression of PIGF in a cell of interest comprising introducing into said cell a siRNA
construct which is homologous to a part of the mRNA sequence of said PIGF
gene. Present invention provides a method for treating Ph+ leukemia in a subject by post-transcriptional gene silencing by RNA
interference (RNAi) PIGF expression in cells and/or RNA interference (RNAi) VEGFR-1 expression in cells. This is a method of particular significance in vivo in a human patient.
Likewise, the use of PIGF
RNAi is envisaged for the treatment of Ph+ leukemia.
dsRNA used to initiate RNAi, may be isolated from native source or produced by known means, e. g.
transcribed from DNA. For example, the binding of an RNA polymerase to a promoter (meaning any double-stranded sequence of DNA comprising a binding site recognised by a DNA-dependent RNA
polymerase) permits initiation of transcription. Many known promoter sequences can be used to produce the dsRNA, for example, but not limited to, the sequences recognised by the RNA polymerases of phages T7, T3 or SP6. This does not, however, represent a limitation, because it will appear clearly to a person skilled in the art that any promoter sequence identified as such, and for which the corresponding RNA polymerase is available, can be used. Alternatively, the two strands of DNA used to form the dsRNA may belong to the same or two different duplexes in which they each form with a DNA
strand of at least partially complementary sequence. When the dsRNA is thus-produced, the DNA
sequence to be transcribed is flanked by two promoters, one controlling the transcription of one of the strands, and the other that of the complementary strand. These two promoters may be identical or different. In fact, in accordance with U. S. Pat. No. 5,795, 715, a DNA duplex provided at each end with a promoter sequence can directly generate RNAs of defined length, and which can join in pairs to form a dsRNA.

The dsRNA, whether of synthetic or natural origin, is subject to rapid degradation by nucleases present in the sera of various animal species, particularly primates. Consequently procedures involving dsRNA
generally utilise baked glassware throughout, and all buffers are filtered, e.
g. through a Nalgene 45 micron filter, for sterility. Pyrogen-free, double distilled water must be used for all solutions to minimise any possibility of endotoxin contamination.
The concentration of the dsRNA solution may be determined from its UV
spectrum. For example, the molar concentration of natural or synthetic dsRNA is determined from the optical density (OD) at 260 nm using an extinction coefficient, obtainable from the literature or determined using standard procedures: 44.7 times 0D260=micrograms dsRNA/ml.
.. If appropriate, the dsRNA solution can be diluted with pyrogen-free buffer for ease in handling. The resulting dsRNA can optionally be linked to a support; or to a ligand, such as biotin, which can be attached to a support coated with avidin. This permits direct quantification, when utilised as an analytical tool.
According to a particular embodiment, the dsRNA compositions of the present invention are prepared as pharmaceutical composition for the treatment of subjects, particularly for the treatment of human patients. More particularly the pharmaceutical compositions are administered to treat Philadelphia chromosome positive leukemia in human patients. In alternative embodiments, the compositions are used to create functional 'knockout model organisms, those in which a target gene is defective, or in this case, expression is inhibited. The dsRNA pharmaceutical composition can be administered locoregionally to said patient. The dsRNA pharmaceutical compositions of the present invention preferably contain a pharmaceutically acceptable carrier or excipient suitable for rendering the compound or mixture administrable e.g. parenterally, intravenously, intradermally, intramuscularly or subcutaneously, or transdermally. The active ingredients may be admixed or compounded with any conventional, pharmaceutically acceptable carrier or excipient.
Selected siRNAs for silencing VEGFR1 gene with high probability of functionality and knocking down more than 90% of the mRNA are available from Dharmacon Inc. Lafayette, CO
80026, USA. A pooling of several different siRNA duplexes all directed against one target gene, called SMARTpooling/SMARTselection is used as an efficient technology for silencing the VEGFR1 gene and/or the PIGF gene. siRNAs against PIGF are also commercially available (e.g. Santa Cruz Biotechnology Inc.).

Anti-sense RNA and DNA molecules act to directly block the translation of mRNA
by binding to targeted mRNA and preventing protein translation. In regard to antisense DNA, oligodeoxyribonucleotides derived from the translation initiation site, e.g. between -10 and +10 regions of the VEGFR-1 or PIGF
nucleotide sequence, are particularly envisaged. For instance the downregulation of another tyrosine kinase receptor, VEGFR2 receptor, achieved by VEGFR2 antisense oligonucleotide transfection, has already been achieved by standard antisense technology (Berard et al., 1997).
Moreover antisense (AS) oligonucleotides directed against the PIGF receptor VEGFR1 has been demonstrated in vivo to block angiogenesis (Marchand et al., 2002). Moreover, antisense inhibition of PIGF
protein production has already been demonstrated by Yonekura et al. (1999).
Both anti-sense RNA and DNA molecules as well as ribozymes may be prepared by any method known in the art for the synthesis of RNA (or DNA) molecules. These include techniques for chemically synthesising oligodeoxyribonucleotides well known in the art such as for example solid phase phosphoramidite chemical synthesis. Alternatively, RNA molecules may be generated by in vitro and in vivo transcription of DNA sequences encoding the antisense RNA molecule. Such DNA sequences may be incorporated into a wide variety of vectors, which incorporate suitable RNA
polymerase promoters such as the T7 or 5P6 polymerase promoters. Alternatively, antisense cDNA
constructs that synthesise anti-sense RNA constitutively or inducibly, depending on the promoter used, can be introduced stably into cell lines.
In a specific embodiment it should be clear that the therapeutic method of the present invention for the treatment of Philadelphia chromosome positive leukemia can also be used in combination with any other therapy known in the art for the treatment of Ph+ leukemia. Particularly envisaged therapies include protein tyrosine kinase inhibitors, particularly BCR/ABL inhibitors, e.g. imatinib and the like.
The term 'medicament as used in the application relates to a composition comprising molecules (inhibitors) as described above and a pharmaceutical acceptable carrier or excipient (both terms can be used interchangeably) to treat diseases as indicated above. Suitable carriers or excipients known to the skilled man are saline, Ringer's solution, dextrose solution, Hank's solution, fixed oils, ethyl oleate, 5%
dextrose in saline, substances that enhance isotonicity and chemical stability, buffers and preservatives. Other suitable carriers include any carrier that does not itself induce the production of antibodies harmful to the individual receiving the composition such as proteins, polysaccharides, polylactic acids, polyglycolic acids, polymeric amino acids and amino acid copolymers. The 'medicament' may be administered by any suitable method within the knowledge of the skilled man.
The preferred route of administration is parenterally.

In parenteral administration, the medicament of this invention will be formulated in a unit dosage injectable form such as a solution, suspension or emulsion, in association with the pharmaceutically acceptable excipients as defined above. However, the dosage and mode of administration will depend on the individual. Generally, the medicament is administered so that the PIGF
inhibitor (e.g. protein, polypeptide, peptide, nucleic acid, compound or molecule) is given at a dose between 1 ug/kg and 10 mg/kg, more particularly between 10 ug/kg and 5 mg/kg, most particularly between 0.1 and 2 mg/kg.
Preferably, it is given as a bolus dose. Continuous infusion may also be used and includes continuous subcutaneous delivery via an osmotic minipump. If so, the medicament may be infused at a dose between 5 and 20 ug/kg/minute, more particularly between 7 and 15 ug/kg/minute.
As used herein, the term "pharmaceutically acceptable carrier" includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic agents, absorption delaying agents, and the like. The use of such media and agents for pharmaceutical active substances is well known in the art. Except insofar as any conventional media or agent is incompatible with the compositions of this invention, its use in the therapeutic formulation is contemplated.
Supplementary active ingredients can also be incorporated into the pharmaceutical formulations.
It will be understood by those skilled in the art that any mode of administration, vehicle or carrier conventionally employed and which is inert with respect to the active agent may be utilised for preparing and administering the pharmaceutical compositions of the present invention. Illustrative of such methods, vehicles and carriers are those described, for example, in Remington's Pharmaceutical Sciences, 4th ed. (1970), the disclosure of which is incorporated herein by reference. Those skilled in the art, having been exposed to the principles of the invention, will experience no difficulty in determining suitable and appropriate vehicles, excipients and carriers or in compounding the active ingredients therewith to form the pharmaceutical compositions of the invention.
The therapeutically effective amount of active agent to be included in the pharmaceutical composition of the invention depends, in each case, upon several factors, e.g. the type, size and condition of the patient to be treated, the intended mode of administration, the capacity of the patient to incorporate the intended dosage form, etc. Generally, an amount of active agent is included in each dosage form to provide from about 0.1 to about 250 mg/kg, and particularly from about 0.1 to about 100 mg/kg. A
'therapeutic amount' or therapeutically effective amount as used herein is an amount that ameliorates one or more symptoms of a disease. Such amount will typically depend on the inhibitor and the severity of the disease, but can be decided by the skilled person, possibly through routine experimentation.
Another aspect of administration for treatment is the use of gene therapy to deliver the above mentioned anti-sense gene or functional parts of the PIGF gene or a ribozyme directed against the PIGF
mRNA or a functional part thereof. Gene therapy means the treatment by the delivery of therapeutic nucleic acids to patient's cells. This is extensively reviewed in Lever and Goodfellow 1995; Br. Med Bull., 51,1-242; Culver et al., 1995; Ledley, 1995. To achieve gene therapy there must be a method of delivering genes to the patient's cells and additional methods to ensure the effective production of any therapeutic genes.
Gene therapy protocols, intended to achieve therapeutic gene product expression in target cells, in vitro, but also particularly in vivo, have been extensively described in the art. These include, but are not limited to, intramuscular injection of plasmid DNA (naked or in liposomes), interstitial injection, instillation in airways, application to endothelium, intra-hepatic parenchyme, and intravenous or intra-arterial administration (e.g. intra-hepatic artery, intra-hepatic vein).
Various devices have been developed for enhancing the availability of DNA to the target cell. A simple approach is to contact the target cell physically with catheters or implantable materials containing DNA.
Another approach is to utilize needle-free, jet injection devices which project a column of liquid directly into the target tissue under high pressure. These delivery paradigms can also be used to deliver viral vectors. Another approach to targeted gene delivery is the use of molecular conjugates, which consist of protein or synthetic ligands to which a nucleic acid-or DNA-binding agent has been attached for the specific targeting of nucleic acids to cells (Cristiano et al., 1993). Target cells will typically depend on which symptoms need to be treated and can be selected by the skilled person (e.g.
bone marrow cells or stromal cells to treat leukemia).
The gene therapy vectors should express a therapeutic amount of the PIGF
inhibitor. According to particular embodiments, the gene therapy vectors described in this application direct the expression of a therapeutic amount of the gene product for an extended period. Indeed, as long as therapeutic levels are achieved, no new treatment is necessary. Typically, therapeutic expression is envisaged to last at least 20 days, at least 50 days, at least 100 days, at least 200 days, and in some instances 300 days or more. Expression of the gene product (e.g. polypeptide, RNAi, etc.) encoded by the coding sequence can be measured by any art-recognized means, such as by antibody-based assays, e.g. a Western Blot or an [LISA assay, for instance to evaluate whether therapeutic expression of the gene product is achieved. Expression of the gene product may also be measured in a bioassay that detects an enzymatic or biological activity of the gene product.
Gene therapy vectors can be episomal vectors (i.e., that do not integrate into the genome of a host cell), or can be vectors that integrate into the host cell genome. Examples of episomal vectors include (extrachromosomal) plasmids and so-called mini-circles, which are composed of the expression cassette only and are devoid of bacterial sequences, and examples of vectors that integrate into the host cell genome including viral vectors.
Representative plasmid vectors include pUC vectors, bluescript vectors (pBS) and pBR322 or derivatives thereof that are devoid of bacterial sequences (minicircles). Some of the plasmid vectors can be adapted to incorporate elements that enhance episomal plasmid persistence in the transfected cells. Such sequences include S/MARs that correspond to scaffold/matrix attached region modules linked to a transcription unit (Jenke et al., 2004; Manzini et al., 2006).
Representative viral vectors include vectors derived from adeno-associated virus, adenovirus, retroviruses and lentiviruses. Alternatively, gene delivery systems can be used to combine viral and non-viral components, such as nanoparticles or virosomes (Yamada et al., 2003).
Retroviruses and lentiviruses are RNA viruses that have the ability to insert their genes into host cell chromosomes after infection. Retroviral and lentiviral vectors have been developed that lack the genes encoding viral proteins, but retain the ability to infect cells and insert their genes into the chromosomes of the target cell (Miller, 1990; Naldini et al., 1996). The difference between a lentiviral and a classical Moloney-murine leukemia-virus (MLV) based retroviral vector is that lentiviral vectors can transduce both dividing and non-dividing cells whereas MLV-based retroviral vectors can only transduce dividing cells.
Adenoviral vectors are designed to be administered directly to a living subject. Unlike retroviral vectors, most of the adenoviral vector genomes do not integrate into the chromosome of the host cell.
Instead, genes introduced into cells using adenoviral vectors are maintained in the nucleus as an extrachromosomal element (episome) that persists for an extended period of time. Adenoviral vectors will transduce dividing and nondividing cells in many different tissues in vivo including airway epithelial cells, endothelial cells, hepatocytes and various tumors (Trapnell, 1993).
Adeno-associated virus (AAV) is a small ssDNA virus which infects humans and some other primate species, not known to cause disease and consequently causing only a very mild immune response. AAV
can infect both dividing and non-dividing cells and may incorporate its genome into that of the host cell. These features make AAV a very attractive candidate for creating viral vectors for gene therapy, although the cloning capacity of the vector is relatively limited.
Another viral vector is derived from the herpes simplex virus, a large, double-stranded DNA virus.
Recombinant forms of the vaccinia virus, another dsDNA virus, can accommodate large inserts and are generated by homologous recombination.
The inhibitors listed herein can be used for the treatment of Philadelphia chromosome positive (Ph+ or BCR-ABL+) leukemia, or be used for the manufacture of a medicament for the treatment of Ph+ (BCR-ABL+) leukemia. Methods for the treatment of Ph+/BCR-ABL+ leukemia will typically involve administration of such PIGF inhibitor to a subject in need thereof, most particularly a human subject. A
particular subset of Ph+ leukemias are the chronic myelogenous leukemias (CMLs). Thus, according to particular embodiments, the uses and methods described in the application are for the treatment of CML. Another important category of Ph+ leukemias is a group of acute lymphocytic leukemias (ALLs) also characterized by the presence of the Philadelphia chromosome. This category typically has a bad prognosis, as many standard treatments fail in Ph+ ALL cases. According to a particular embodiment, the other leukemias wherein the Philadelphia chromosome (or the BCR-ABL fusion protein) is present may also be suitable for the uses and methods described herein. However, these cases are less common than CML or ALL. Nevertheless, some cases of Ph+ AML (acute myeloid leukemia) have been reported, and such cases of Ph+ leukemia are also envisaged to benefit from the uses and methods provided in the application.
It is important to realize that leukemias are devastating diseases, often with a bad prognosis for the patient. Therefore, it is important to be able to offer alternative treatment strategies, or combination strategies, if one approach of treatment fails. It is a goal of the present application to provide therapeutic benefit, in particular also to patients that do not benefit from other treatment regimen.
The standard treatment for Philadelphia chromosome positive leukemias, in particular for CML, is the use of a BCR-ABL inhibitor or a tyrosine kinase inhibitor. The best known example of this type of drugs is imatinib, but several other examples exist, such as nilotinib (AMN107), dasatinib (BM5354825), AT9283 (Astex therapeutics), SGX393 (Eli Lilly), INNo-406 (Innovive Pharmaceuticals), bosutinib (5KI606), and MK0457 (Merck).
However, several reports indicate that resistance against these medicines is a common problem.
Indeed, leukemia cells persist even in successfully treated patients, and some patients develop resistance and ultimately relapse (Swords et al., 2007; Buchert, 2007; Li and Li, 2007; Kujawski and Talpaz, 2007). According to particular embodiments, the PIGF inhibitors are used for the treatment of Ph+ leukemias which can not be treated with a BCR-ABL inhibitor, and/or in more particular cases can not be treated with a BCR-ABL inhibitor alone. Philadelphia chromosome positive leukemias may not be treatable with a BCR-ABL inhibitor (or a BCR-ABL inhibitor alone) for a variety of reasons, the two most common being insensitivity of the malignant cells to the BCR-ABL
inhibitor and the medicine not being tolerated by the patient.
Insensitivity of the leukemia cells to the BCR-ABL inhibitor may be due to several mechanisms (Shah and Sawyers, 2003), and may arise from onset (i.e. insensitivity at the first treatment) or the resistance may be acquired (e.g. in patients showing relapse, or in patients having a further developed leukemia, for instance in a blast crisis stage).
Also, BCR-ABL inhibitors have been known to invoke adverse side-effects in patients, which may lead to the medicament not being suitable anymore for particular patients. An allergic reaction in a patient may also lead to intolerance to the medicine.
According to specific embodiments, the PIGF inhibitors are used for the treatment of Ph+ leukemias which are (at least partially) resistant to treatment with a BCR-ABL
inhibitor. Leukemias which are (partially) resistant to a BCR-ABL inhibitor can be defined as leukemias in which leukemic cells are present that have a diminished response to the BCR-ABL inhibitor. The amount of cells having a diminished response is indicative of the degree of resistance to the BCR-ABL
inhibitor. Typically, although not necessarily, (partial) resistance to a BCR-ABL inhibitor is an acquired phenomenon.
According to further specific embodiments, the PIGF inhibitors are used for the treatment of imatinib-.. resistant Ph+ leukemias. Non-limiting examples of such leukemias include imatinib-resistant Ph+ CML, imatinib-resistant Ph+ ALL, e.g. imatinib-resistant Ph+ T-ALL, imatinib-resistant Ph+ B-ALL.
Sometimes, although certainly not in all cases, the resistance to BCR-ABL
inhibitors, in particular resistance to imatinib, is associated with mutations in the BCR-ABL gene, in particular in the tyrosine kinase domain. The T315I mutation is the best known example hereof. Other examples include the E255K, E255V, Y253H, H396P, F317L, M351T, G250E, F311L, M244V, F359V, L387M, H396R, 0252H, Y253F, 0252R, and E355G mutations (Shah and Sawyers, 2003). Corbin et al.
reported that especially G250E, H396P, H396R, E255V and T315I appeared to confer resistance to imatinib (Corbin et al., 2003).
According to particular embodiments, the PIGF inhibitors are used for the treatment of Ph+ leukemias in which the BCR-ABL gene has at least one mutation. According to further particular embodiments, the PIGF inhibitors are used for the treatment of Ph+ leukemias which can not be treated with a BCR-ABL inhibitor and/or not be treated with a BCR-ABL inhibitor alone, and in which the BCR-ABL gene has at least one mutation. According to still further particular embodiments, the Ph+ leukemias can not be treated with imatinib or not be treated with imatinib alone. According to still more specific embodiments, the at least one mutation in the BCR-ABL gene is selected from the group consisting of the T315I, E255K, E255V, Y253H, H396P, F317L, M351T, G250E, F311L, M244V, F359V, L387M, H396R, 0252H, Y253F, 0252R, and E355G mutations.
It is envisaged that the use of an inhibitor of placental growth factor for the treatment of Philadelphia chromosome positive leukemia can be a stand-alone therapy or method of treatment. According to particular embodiments, however, the use of PIGF inhibitors in the treatment of Ph+ leukemias is envisaged as part of a combination therapy. Thus, PIGF inhibition may be used together with other therapies used to treat Ph+ leukemias, such as radiotherapy, chemotherapy, biological therapy (e.g.
interferon treatment), stem cell transplantation, bone marrow transplantation, surgery (e.g. spleen removal), or targeted therapies such as BCR-ABL inhibition, Lyn inhibition, Hsp90 inhibition, Src inhibition. Of course, PIGF inhibition may be used in combination with more than one of these therapies (e.g. together with BCR-ABL and Lyn inhibition).
PIGF inhibition may be done concomitant with other therapies, or either before or after other therapies, or they may e.g. be intermittently changed. The skilled person is able to decide on the optimal treatment regimen, optionally after routine experimentation.
It is to be understood that although particular embodiments, specific configurations as well as materials and/or molecules, have been discussed herein for cells and methods according to the present invention, various changes or modifications in form and detail may be made without departing from the scope and spirit of this invention. The following examples are provided to better illustrate particular embodiments, and they should not be considered limiting the application. The application is limited only by the claims.
Examples Materials and methods Animals Female Balb/c mice (8 weeks old) were obtained from Janvier. Housing and all experimental animal procedures were approved by the Institutional Animal Care and Research Advisory Committee of the K.U. Leuven.
Cells and culture conditions KCL-22 and CRL-1929 cells were obtained from ATCC. 13v-173, K562, BaF3, 32D
and Nalm6 cells were kindly provided by J. Cools (VIB, Leuven). 13v-173 cells and K562 cells were cultured in RPM! medium (Gibco, Invitrogen Corporation) with 20% FCS (Hyclone Laboratories); BaF3, 32D
and KCL-22 cells were cultured in RPM! medium with 10% FCS; Nalm 6 cells were cultured in DMEM
medium (Gibco, Invitrogen Corporation) with 10% FCS and CRL-1929 cells were cultured in IMDM
medium (Gibco, Invitrogen Corporation) with 20% FCS and 0.05 mM beta-mercaptoethanol (Gibco, Invitrogen Corporation).
Isolation of primary murine bone marrow-derived stromal cells (BMDSCs) For isolation of BMDSCs, the bone marrow from femurs and tibias was flushed, the erythrocytes eliminated with lysis buffer (150 mM NH4CI, 0.1 mM EDTA, 10 mM KHCO3, pH 7.4) and subsequently the cells were cultured in DMEM medium supplemented with 15% FCS. After 24 hours, the non-adherent cell fraction was removed, and the adherent cells were further cultured and expanded for 3 weeks.
Proliferation assays and co-cultures Proliferation of leukemia cells and BMDSCs was analyzed by using MTT assays or by manual counting with a hemocytometer. Murine recombinant PIGF and anti-VEGFR-1 were obtained from R&D Systems.
Anti-PIGF and control IgG1 were produced by Thrombogenics and Biolnvent and characterized as described (Fischer et al., 2007). PIGF was used at a concentration of 50 ng/ml and the antibodies in 100-fold molar excess, unless stated otherwise. For co-culture experiments, 105 BMDSCs were co-cultured for 48 hours with 4x105 leukemia cells alone or in presence of the respective antibodies in serum-free medium. Subsequently, numbers of adherent BMDSCs and non-adherent leukemia cells were determined and supernatants were harvested for analyses of PIGF and VEGF
protein.
Peripheral blood analysis Blood was collected with capillary pipettes by retro-orbital bleeding, and white blood cell count (WBC) determined using an automated cell counter (Beckman Coulter).
ELISA
Concentrations of PIGF or VEGF were quantified in cell culture supernatants, peripheral blood plasma and bone marrow plasma using "Quantikine" mouse PIGF and mouse VEGF
immunoassays (R&D
Systems). Concentrations were expressed as pg/mI/105 cells or as pg/ml.
Quantitative real-time PCR

RT-PCR was essentially carried out with primers and probes as described previously (Fischer et al., 2007).
Syngeneic model of BCR-ABL+ Pre-B cell leukemia BCR-ABL+ BaF3 cells were cultured as described above and 1x106 cells were injected via the tail vein into syngeneic 8 weeks old Balb/C mice.
Transplantation models of imatinib-sensitive and imatinib-resistant CML
For induction of CML, bone marrow cells were harvested by flushing of femurs and tibias from Balb/C
.. donors (8 weeks) 4 days after treatment with 200 mg/kg 5-fluorouracil (5-FU; Sigma Aldrich) and pre-stimulated in vitro in medium containing 10 ng/ml IL-3, 10 ng/ml IL-6 and 50 ng/ml SCF. Subsequently, the cells were subjected to 1 round of co-sedimentation with retroviral stocks (retroviral constructs:
MCSV-GFP, MSCV-BCR-ABL p210 IRES-EGFP, MSCV-BCR-ABL-T3151-IRES-EGFP; kindly provided by Jan Cools). Recipient female mice were prepared by lethal irradiation, and transduced marrow was transplanted by intravenous injection of 0.5x106 cells per animal.
Example 1. Analysis of PIGF expression in leukemia cells and primary bone marrow stromal cells in vitro.
In order to determine the expression profile of PIGF by leukemia cells and by different populations of leukemia-associated stromal cells in vitro, PIGF expression was analyzed in a set of BCR-ABL+ myeloid and lymphoid cell lines (murine: BaF3, 32D; human: K562, Bv-173, KCL-22). In addition, the human BCR-ABL- lymphoid cell line Nalm-6 was investigated. Furthermore, PIGF expression was quantified in different populations of bone marrow stromal cells. No expression of PIGF
protein was found in all studied leukemia cell lines as determined by [LISA and very low amounts (41 2.3 pg/ml) in healthy CD45+ hematopoietic cells isolated from murine bone marrow (Figure 1A). In contrast, murine primary bone marrow-derived stromal cells (BMDSCs) and stromal cell lines (S17, 0P9) expressed abundant amounts of PIGF protein (Figure 1A).
FACS analysis of bone marrow-derived stromal cells revealed that 49.7% 20%
of murine BMDSCs were of hematopoietic lineage after a mean culture period of 3 weeks (not shown). To unravel, whether the hematopoietic fraction (CD45+) or the non-hematopoietic fraction (CD45-) of murine BMDSCs expressed PIGF, we separated both populations via an immunomagnetic approach (purity>93%, not shown) and subsequently determined PIGF in the supernatants of CD45+ and CD45-BMDSC5. These experiments revealed almost exclusive expression of PIGF by CD45-BMDSCs (Figure 1B) (N=3; p<0,001). Furthermore, we determined PIGF expression in human (HUVEC) and murine (fEND5) endothelial cells and found abundant expression of PIGF protein (HUVEC: 279,7 29,9 pg/ml; fEND5:
125,7 18,8 pg /ml; N=3) Altogether, these results point into the direction that PIGF is mainly expressed by bone marrow stromal cells and not by leukemia cells in vitro.
Example 2. PIGF is expressed by the leukemic stroma and represents a biomarker of leukemia progression in vivo.
To elucidate a potential impact of PIGF on leukemia disease progression and hence therapeutic potential of aPIGF in vivo, a well-described blast crisis model of CML was used by transplanting BCR/ABL-GFP transduced bone marrow into syngeneic, sublethally irradiated mice. We first analyzed PIGF protein levels in the plasma of diseased mice at different timepoints (d14, d21 and d28) compared to control mice, and detected very low amounts of PIGF protein in the peripheral blood of healthy mice or mice transplanted with mock-transduced bone marrow and low amounts of PIGF
protein in their bone marrow. In contrast, leukemic mice showed increasing PIGF protein upon disease progression in their circulation reaching levels comparable to mice bearing solid tumors (Fischer et al., 2007) at end-stage (Figure 2A, B). A similar kinetic of PIGF increase was observed in bone marrow plasma (Figure 2B). We also quantified the natural inhibitor of PIGF, 5VEGFR-1, and found that although 5VEGFR-1 is present in excess compared to PIGF, the ratio PIGF/5VEGFR-1 increases in blood and bone marrow upon disease progression, indicating that upregulation of PIGF is more pronounced than of 5VEGFR-1 during the course of leukemia (Figure 2C, D).
To dissect the source of PIGF in vivo, we performed Real-Time PCR analyses of bone and bone marrow, revealing 12.6-fold upregulation of PIGF mRNA in the bone marrow (N=8;
P<0.002) (Figure 2E). PIGF
mRNA levels in the bones were similar in diseased and healthy mice (data not shown), indicating that the primary source of elevated PIGF detected in the bone marrow plasma of leukemic mice is the bone marrow. To further specify the PIGF producing cells within the bone marrow, we FACS-sorted leukemia cells (GFP+), non-leukemic hematopoietic cells (GFP-CD45+) and non-leukemic, non-hematopoietic stromal cells (GFP-CD45-) and subsequently determined PIGF mRNA expression by means of RT-PCR in these subfractions. These experiments elucidated, similar to the above-mentioned in vitro findings, that PIGF is predominantly expressed by CD45- stromal cells and only negligibly by leukemia cells or hematopoietic cells in leukemic mice in vivo. Indeed, GFP-CD45- stromal cells expressed 95,6-fold more PIGF mRNA than leukemia cells and 32-fold more PIGF mRNA than hematopoietic cells (N=4; P<0,05);
Figure 2F). When comparing PIGF mRNA levels in CD45- bone marrow cells from leukemic mice with PIGF mRNA levels in CD45- cells from the bone marrow of healthy mice, we found a strong (25,4-fold) upregulation of PIGF expression within the non-hematopoietic stromal cell compartment of mice bearing leukemia (N=4; P<0,05) (Figure 2F). Interestingly, VEGF mRNA was only slightly upregulated in the bone marrow of mice bearing leukemia when compared to healthy mice (N=8;
P=0.23) (Figure 2G) indicating that PIGF represents a specific, stroma-derived pathogenic factor in BCR/ABL+ leukemia also in vivo. This hypothesis is further corrobated by the observation, that the amount of PIGF protein present in the blood plasma or bone marrow plasma of leukemic mice correlates with the number of leukemic blasts infiltrating the bone marrow, as determined by FACS analysis of GFP+ cells in the bone marrow of end-stage diseased mice (r= 0.81 and r=0.85; p<0.05; Figure 2H, l).
Hence, PIGF represents a biomarker of disease progression of blast crisis CML in mice.
Example 3. Anti-PIGF inhibits PIGF-induced proliferation of leukemia cells.
To determine a potential biological effect of PIGF on leukemia cells, expression of the main PIGF
receptor, VEGFR-1 and its co-receptors Npn1 and Npn2 in leukemia cell lines was investigated. VEGFR-1 was expressed by most studied cell lines in accordance with the published literature (Fragoso et al., 2006) (data not shown). Npn1 and Npn2 were expressed in K562, Nalm-6, BV-173 and KCL-22 cell lines, albeit at different levels, but not in 32D cells (Figure 3A, B). Based on these findings, we incubated leukemia cells with PIGF in vitro, which dose dependently induced proliferation of 4 out of 5 BCR/ABL+
cell lines, in concordance with the published literature (Figure 3C, D). In addition to its main receptor VEGFR-1, PIGF also binds to the co-receptors Npn-1 and Npn-2. To unravel whether PIGF-induced proliferation of leukemia cells requires VEGFR-1, the inhibitory effect of an extracellular VEGFR-1 blocking antibody (aVEGFR-1) was evaluated. Inhibition of PIGF mediated proliferation in presence of aVEGFR-1 was found (Figure 3E). In contrast, PIGF-induced proliferation of leukemia cells was not inhibited upon addition of extracellular, function blocking antibodies against Npn-1 and Npn-2, indicating that the pro-proliferative effect of PIGF is primarily mediated via VEGFR-1. (Figure 1G). In a next step, it was investigated if anti-PIGF (aPIGF) inhibits PIGF induced proliferation of leukemia cells and nearly complete abrogation of the pro-proliferative effect of PIGF upon addition of aPIGF was found, indicating therapeutic potential in leukemia (Figure 3F).
In order to elucidate, whether PIGF induces changes in ABL phosphorylation of BCR/ABL+ leukemia cells, we performed Western Blots of Bv-173 and KCL-22 cells that were incubated with and without PIGF. These experiments indicated that PIGF did not modify phosphorylation of ABL (data not shown).
Example 4. Paracrine interactions between leukemia cells and BMDSCs induce PIGF secretion by BMDSCs.
Co-culture experiments were performed to study potential interactions between human leukemia cells and murine BMDSCs or a murine bone marrow stromal cell line (S17) leading to increased PIGF
secretion by either BMDSCs or S17 cells and significant upregulation of murine PIGF upon co-culture was found (Figure 4A,B). This finding prompted us to analyze proliferation of the co-cultures, which revealed significant induction of proliferation of leukemia cells and BMDSCs (Figure 4C, D). This pro-proliferative effect was almost entirely abrogated upon addition of aPIGF to the cultures, indicating that PIGF can induce proliferation of leukemia cells in a paracrine manner, but at the same time mediates expansion of bone marrow stromal cells via an autocrine loop, thus simultaneously promoting the leukemic clone and its supportive stroma (Figure 4C, D).
Interestingly, this interaction specifically leads to PIGF upregulation, because VEGF was not upregulated upon co-culture (data not shown). To test the potential role of PIGF in BCR-ABL+ leukemia in vivo, 3 different murine models of BCR/ABL+ myeloid and lymphoid leukemia were established.
In an effort to unravel molecular signals that might induce upregulation of PIGF, we first analyzed, whether incubation with leukemia-cell conditioned medium (CM) would be sufficient to induce similar upregulation of PIGF in stromal cells (S17) than direct co-culture with leukemia cells, and found that indeed CM is sufficient for induction of PIGF secretion by S17 (N=3; P=0,008;
Figure 4E).

Example 5. Genetic deficiency of the host stroma, but not of the leukemia cells prolongs survival of leukemic mice.
To determine the role of PIGF in BCR/ABL+ leukemia in vivo, we induced leukemia in mice genetically deficient for PIGF (PIGF-/-) and in wt mice (WT) and compared the survival between both groups. We found that mice lacking PIGF lived significantly longer than WT mice, indicating that PIGF plays an important role in the pathogenesis of leukemia in vivo. (N=14/15; P=0.003;
Figure 5A).
In an attempt to proof our hypothesis that PIGF represents a stroma-derived factor in BCR/ABL+
leukemia, we performed cross-over studies by transplanting transduced bone marrow cells from WT
mice and PIGF KO mice into WT hosts and compared survival between the different groups (WT¨*WT, KO¨*WT and WT¨>K0). We found that absence of PIGF in the leukemia cells did not prolong the survival of mice, but that PIGF deficiency of the host stroma induced a significant survival advantage in leukemic mice, which is in a comparable range as in the fully PIGF deficient system (see above). Thus, stromal derived PIGF critically promotes progression of BCR/ABL+ leukemia in vivo (Figure 5B).
Example 6. Treatment of leukemic mice with anti-PIGF significantly prolongs their survival.
In order to investigate the therapeutic potential of PIGF inhibition in murine Ph+ leukemia, mice bearing leukemia induced by intravenous injection of BCR-ABL+ BaF3 cells were treated with aPIGF, and a significant prolongation of median survival by 18 days was found (N=9;
P=0.015), compared to control antibodies (Figure 5C). These results prompted us to establish murine models of imatinib-sensitive and imatinib-resistant (T315I mutant) CML, induced by transplantation of BCR-ABL
transduced BM, clinically mimicking the human disease condition in blast crisis characterized by splenomegalia and excessive proliferation of myeloid leukemia cells leading to death of diseased mice one week after elevated leukocytes can be first detected in the peripheral blood. Thereafter, the effect .. of aPIGF on the leukemic burden, bone marrow histology and survival of mice was investigated.
Reduced leukemic burden was observed (data not shown) and FACS analysis of GFP+ cells at early stage (d15) and end-stage (d28) leukemia revealed specific reduction of BCR-ABL+
cells in BM and PB (N=7;
P<0,05)(Figure 5D, E and not shown). Furthermore, bone marrow histologies at end-stage indicate a substantial inhibition of disease progression induced by treatment with aPIGF
(Figure 5F). Thereafter, we investigated the effect of ocPIGF on survival of mice. These experiments indicate significant prolongation of survival upon treatment with ocPIGF when compared to control antibodies in mice bearing both Imatinib-sensitive and ¨resistant leukemia (Figure 5G, H). Thus, aPIGF inhibits progression of murine blast crisis leukemia independent of BCR/ABL mutational status.
Example 7. Treatment of leukemic mice with anti-PIGF inhibits bone marrow hypervascularization and fibrosis.
Neoangiogenesis of the bone marrow represents an important pathogenic factor in leukemia. PIGF is a potent pro-angiogenic cytokine and was already shown to promote tumor angiogenesis. Therefore, the effect of PIGF inhibition on bone marrow vascularization was analyzed by morphometric analysis of CD31 stainings in mock-transplanted, control antibody-treated and aPIGF-treated mice with end-stage leukemia. These experiments indicated a profound hypervascularization of the bone marrow in leukemic mice compared to mock-transplanted controls (Figure 6 A, C). This hypervascularization is significantly reduced after treatment with aPIGF (Figure 6A, C).
Bone marrow fibrosis is a well known adverse factor in CML and is associated with resistance to Imatinib. Based on our observations that PIGF stimulates proliferation of BMDSCs (see above), we investigated whether treatment of leukemic mice with aPIGF could modify bone marrow fibrosis. Upon morphometric analysis of the average length of reticulin+ fibers in the bone marrow we found a significant reduction of bone marrow fibrosis induced by inhibition of PIGF
(Figure 6B, D). Hence, aPIGF
reduces both hypervascularization and fibrosis of the bone marrow in leukemic mice.
Interestingly, initial experiments have shown that imatinib and anti-PIGF have an additive inhibitory effect on BCR/ABL+ leukemia in vivo.
Example 8. PIGF is upregulated in human CML.
To investigate the relevance of PIGF as novel target molecule in human CML, we determined PIGF
plasma levels in healthy controls (n=10), untreated patients in Chronic Phase (CP) upon primary diagnosis (n=32) and patients with blast crisis (BC, terminal phase of the disease) under treatment with different tyrosine kinase inhibitors (TKIs) (n=9). These analyses revealed 2.1-fold upregulation of PIGF
in newly diagnosed patients in CP (p<0.0001) and 3.7-fold increase of PIGF
levels in patients with BC

(p<0.0001) compared to healthy controls (Figure 7A). Subsequently, we determined PIGF levels in the bone marrow plasma (BMP) of patients with newly diagnosed CML (n=7) and in control patients diagnosed with lymphoma without invasion of the bone marrow (n=5; Figure 7B).
These analyses revealed an upregulation of PIGF also in BMP of CML patients compared to controls.
We then investigated a potential relation between PB PIGF protein and BCR-ABLi transcript numbers as determined by QRT-PCR in a single centre (n=43 CP, n=2 Accelerated Phase;
treatment with different TKIs, imatinib+interferon, or homoharringtonine). We found a significant correlation between PIGF
levels and BCR-ABLi transcript numbers (r=0.45; p=0.0016), indicating that PIGF represents a disease specific target in human CML (Figure 7C). Subsequently, we isolated CD34+
cells from healthy donors and from CML patients in CP and BC and determined PIGF expression by QRT-PCR.
These analyses revealed that PIGF expression is equally low in leukemia cells as in healthy CD34+ cells (Figure 7D).
Thus, elevated circulating PIGF is most likely not secreted by leukemia cells, but by stromal cells. To investigate this hypothesis, we isolated adherent BM stromal cells from patients with newly diagnosed CML and compared PIGF expression levels to those in CD34+ leukemia cells. We found that stromal cells express >7-fold more PIGF than leukemia cells (Figure 7D; p=0.003), which corroborates our preclinical data and extends the concept that PIGF is primarily produced by stromal cells in CML
patients.
Example 9. PIGF levels in CML patients under imatinib remain elevated.
It still remains unclear, why leukemia cells persist in patients treated with imatinib, which cause rapid relapse of most patients after withdrawal of the drug. The host stroma potentially plays an important role, independent of the BCR/ABL+ leukemia cells. To elucidate, if imatinib can induce PIGF secretion by BMDSCs, we incubated stromal cells with increasing concentrations of imatinib.
These experiments revealed dose-dependent induction of PIGF in murine BMDSCs indicating a potential role of stroma-derived PIGF in mediating resistance to imatinib. In order to elucidate whether this induction of PIGF in BMDSCs also occurs in vivo, we treated mice bearing CML induced by transplantation of BCR/ABL
transduced bone marrow with imatinib and compared PIGF levels in their bone marrow with untreated leukemic mice and healthy mice. These experiments revealed upregulation of PIGF in the bone marrow of leukemic mice treated with imatinib compared to untreated mice, even though bone marrow infiltration of imatinib treated mice with leukemia cells was significantly lower (Figure 7E) These results indicate potentiation of leukemia-induced PIGF expression in the bone marrow by imatinib, which might promote leukemia cell survival and proliferation in presence of imatinib.
These findings prompted us to determine PIGF levels in the PB of patients treated with Imatinib reaching different response levels (complete molecular remission CM R;
BCR/ABL/ABL ratio <1;
BCR/ABL/ABL ratio <10) and to compare them to healthy individuals and untreated, primarily diagnosed CML patients. Interestingly, PIGF levels were significantly higher in patients with CMR than in healthy subjects, and in patients with a low BCR/ABL/ABL ratio <1, PIGF was elevated to similar levels as in untreated, newly diagnosed CML patients (Figure 7F). These data indicate that PIGF remains elevated despite reduction of leukemic burden by several orders of magnitude and might contribute to persistence of disease under treatment with Imatinib.
In conclusion, our data indicate that PIGF represents a stromal derived factor promoting the progression of Ph+ leukemia, independent of BCR/ABL mutational status, and represents a novel target produced by the leukemic stroma, useful adjunct to BCR/ABL kinase inhibitors or in TKI refractory leukemia.
Discussion Introduction of Imatinib and second-generation BCR-ABL inhibitors has revolutionized treatment of patients with Philadelphia chromosome positive (Ph+) leukemias, but leukemia cells persist even in successfully treated patients, and some patients develop resistance and ultimately relapse. The reasons for these drawbacks are not entirely resolved, but it was postulated by us that the host stroma potentially plays an important role independent of BCR-ABL. Placental Growth Factor (PIGF), a homologue of VEGF, was already proven to be abundantly secreted by stromal cells in solid tumors.
Therefore, it was decided worthwhile to study the role of PIGF in Ph+ lymphoid and myeloid leukemias, and to address the therapeutic potential of aPIGF, a monoclonal antibody against PIG F, which we recently reported to have a broad anti-tumoral potential in a variety of pre-clinical models of solid tumors (Fischer et al., Cell, 2007).
First, expression of PIGF by 5 different human and murine Ph+ leukemia cell lines (Bv-173, BaF3, 32D, K562, KCL22) was studied in vitro and none of these cell lines was found to secrete PIGF protein, although they expressed its target receptor VEGFR-1. In contrast, primary murine adherent bone marrow stromal cells (BMDSC) expressed abundant amounts of PIGF protein (up to 105 pg/mI/105 cells), indicating a potential stroma-related function of PIGF.
Second, it was analyzed whether PIGF could induce proliferation and thereby dose-dependent induction of proliferation by recombinant PIGF was revealed in all analyzed leukemia cell lines. This effect of PIGF was nearly completely abrogated by both aPIGF and an extracellular anti-VEGFR-1 antibody, thus indicating that the pro-proliferative effect of PIGF is mediated primarily by VEGFR-1.
Third, potential paracrine interactions between BMDSCs and leukemia cells were studied by performing co-culture experiments. Remarkably, co-culture of BMDSC with leukemia cells significantly induced proliferation of leukemia cells. It was hypothesized that this induction of proliferation might be mediated by PIGF and indeed, nearly complete abrogation of this pro-proliferative effect upon addition of aPIGF to the co-cultures was found. Furthermore, BDMSCs significantly upregulated PIGF
secretion (2.1 fold; N=3; P=0.005) when cultured in presence of leukemia cells, indicating substantial paracrine interactions between both cell types. These results allowed us to conclude, that stromal derived PIGF might represent a novel target in Ph+ leukemias.
To test this hypothesis in vivo, 3 different murine models of Ph+ myeloid and lymphoid leukemia were established. Subsequently, PIGF protein as present in blood and bone marrow of diseased mice in comparison to healthy mice was analyzed. No PIGF protein was found in the peripheral blood of healthy mice and low amounts of PIGF protein in their bone marrow. In contrast, leukemic mice showed PIGF protein (76.5 18.4 pg / ml plasma; N=7) in their circulation at levels comparable to mice bearing solid tumors, and, interestingly more than 8.9 fold (N=7; P<0.0001) elevated PIGF levels in their bone marrow, compared to healthy mice, again indicating that PIGF represents a stroma derived, novel pathogenetic factor in Ph+ leukemia.
In order to investigate the therapeutic potential of aPIGF in murine Ph+
leukemias, subsequently mice bearing leukemia induced by injection of BCR/ABL+ BaF3 cells were treated with aPIGF compared to control antibodies, and found a significant prolongation of median survival by 18 days (N=9; P=0.015) induced by aPIGF. Encouraged by these positive results, models of Imatinib-sensitive and Imatinib-resistant (T315I mutant) CML were established by transducing primary bone marrow cells and subsequent transplantation into lethally irradiated recipient mice, which were treated with aPIGF and control antibodies. Interestingly, also in these aggressive models, we found a significant prolongation of survival of diseased mice induced by blockade of PIGF (median survival prolongation in wt BCR-ABL

induced leukemia 5 days; N=11; P=0.002; in T315I mutant 4 days; N=12;
P=0.039). Bone marrow histology and phenotypic analysis by FACS revealed decreased infiltration of spleen and bone marrow with leukemia cells (reduction in the bone marrow by 38% and in the spleen by 24%).
We here unravel that leukemia cells instruct non-hematopoietic bone-marrow derived stromal cells (BMDSCs) to upregulate placental growth factor (PIGF), which critically drives progression of BCR-ABL1+ leukemia in preclinical mouse models. Importantly, these findings were confirmed in human samples of CML, as PIGF is also upregulated in blood and bone marrow of CML
patients. Inhibition of this novel target molecule by a monoclonal antibody against PIGF, aPIGF, enhances survival of mice bearing Imatinib-sensitive and ¨resistant (T3151-mutated) leukemia. Anti-PIGF
exhibits therapeutic efficacy by blocking proliferation of leukemia cells and by normalizing the abnormal leukemic bone marrow microenvironment by reducing hypervascularization and fibrosis.
Interestingly, Imatinib can upregulate PIGF in BMDSCs and PIGF levels remain high in CML patients treated with Imatinib, indicating that PIGF might contribute to persistence of leukemia cells. This further supports the fact that PIGF inhibition can be used in combination with such therapies, giving additional benefit.ln summary inhibition of PIGF may serve as a new candidate to be targeted in combination therapies or in TKI refractory CML.
In conclusion, these data indicate that PIGF represents a stromal derived factor promoting the progression of Ph+ leukemia, independent of BCR-ABL mutational status, and might represent a novel target produced by the leukemic stroma, potentially useful adjunct to BCR-ABL
kinase inhibitors.

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Claims (28)

45

1. A selective inhibitor of placental growth factor for use in the treatment of Philadelphia chromosome positive leukemia in a subject, wherein said inhibitor is an antibody or a fragment thereof that specifically binds to placental growth factor and inhibits binding of placental growth factor to VEGFR1, wherein the Philadelphia chromosome positive leukemia cannot be treated with a BCR-ABL inhibitor, or cannot be treated with a BCR-ABL inhibitor alone.

2. The selective inhibitor for use according to claim 1, wherein the Philadelphia chromosome positive leukemia is chronic myelogenous leukemia, acute myeloid leukemia, or acute lymphocytic/lymphoblastic leukemia.

3. The selective inhibitor for use according to any one of claims 1 to 2, wherein the antibody is the antibody 16D3 as produced by the cell line deposited under accession number LMBP 6399CB, or a humanized version thereof, or a fragment thereof that specifically binds to placental growth factor.

4. The selective inhibitor for use according to any one of claims 1 to 3, wherein the Philadelphia chromosome positive leukemia cannot be treated with a BCR-ABL inhibitor which is a tyrosine kinase inhibitor.

5. The selective inhibitor for use according to any one of claims 1 to 4, wherein the Philadelphia chromosome positive leukemia cannot be treated with imatinib, nilotinib, dasatinib, bosutinib, AT9283, SGX393, INNo-406 or MK0457.

6. The selective inhibitor for use according to any one of claims 1 to 5, wherein the subject has been previously treated with a BCR-ABL inhibitor, and either (a) developed insensitivity to the BCR-ABL inhibitor, or (b) the BCR-ABL inhibitor was not tolerated by the subject.

7. A combination of a selective inhibitor of placental growth factor and a BCR-ABL inhibitor for use in the treatment of Philadelphia chromosome positive leukemia in a subject, wherein said inhibitor is an antibody or a fragment thereof that specifically binds to placental growth factor and inhibits binding of placental growth factor to VEGFR1, wherein the Philadelphia chromosome positive leukemia cannot be treated with a BCR-ABL inhibitor alone.

8. The combination for use according to claim 7, wherein the Philadelphia chromosome positive leukemia is chronic myelogenous leukemia, acute myeloid leukemia, or acute lymphocytic/lymphoblastic leukemia.

9. The combination for use according to any one of claims 7 to 8, wherein the antibody is the antibody 16D3 as produced by the cell line deposited under accession number LMBP 6399CB, or a humanized version thereof, or a fragment thereof that specifically binds to placental growth factor.

10. The combination for use according to any one of claims 7 to 9, wherein the BCR-ABL inhibitor is a tyrosine kinase inhibitor.

11. The combination for use according to any one of claims 7 to 10, wherein the BCR-ABL inhibitor is imatinib, nilotinib, dasatinib, bosutinib, AT9283, SGX393, INNo-406 or MK0457.

12. The combination for use according to any onc of claims 7 to 11, wherein the subject has been previously treated with a BCR-ABL inhibitor, and either (a) developed insensitivity to the BCR-ABL inhibitor, or (b) the BCR-ABL inhibitor was not tolerated by the subject.

13. Use of a selective inhibitor of placental growth factor for the manufacture of a medicament for the treatment of Philadelphia chromosome positive in a subject, wherein the selective inhibitor of placental growth factor is an antibody or a fragment thereof that specifically binds to placental growth factor and inhibits binding of placental growth factor to VEGFR I , wherein the Philadelphia chromosome positive leukemia cannot be treated with a BCR-ABL inhibitor, or cannot be treated with a BCR-ABL inhibitor alone.

14. Use of a combination of a selective inhibitor of placental growth factor and a BCR-ABL inhibitor for the manufacture of a medicament for the treatment of Philadelphia chromosome positive leukemia in a subject, wherein the selective inhibitor of placental growth factor is an antibody or a fragment thereof that specifically binds to placental growth factor and inhibits binding of placental growth factor to VEGFR1, wherein the Philadelphia chromosome positive leukemia cannot be treated with a BCR-ABL
inhibitor alone.

15. The use according to any one of claims 13 to 14, wherein the Philadelphia chromosome positive leukemia is chronic myelogenous leukemia, acute myeloid leukemia, or acute lymphocytic/lymphoblastic leukemia.

16. The use according to any one of claims 13 to 15, wherein the antibody is the antibody 16D3 as produced by the cell line deposited under accession number LMBP 6399CB, or a humanized version thereof, or a fragment thereof that specifically binds to placental growth factor.

17. The use according to any one of claims 13 to 16, wherein the BCR-ABL
inhibitor is a tyrosine kinase inhibitor.

18. The use according to any one of claims 13 to 17, wherein the BCR-ABL
inhibitor is imatinib, nilotinib, dasatinib, bosutinib, AT9283, SGX393, INNo-406 or MK0457.

19. The use according to any one of claims 13 to 18, wherein the subject has been previously treated with a BCR-ABL inhibitor, and either (a) developed insensitivity to the BCR-ABL
inhibitor, or (b) the BCR-ABL inhibitor was not tolerated by the subject.

20. A medicament for the treatment of Philadelphia chromosome positive leukemia in an individual comprising a selective inhibitor of placental growth factor, wherein the selective inhibitor of placental growth factor is an antibody or a fragment thereof that specifically binds to placental growth factor and inhibits binding of placental growth factor to VEGFR1, wherein the Philadelphia chromosome positive leukemia cannot be treated with a BCR-ABL inhibitor, or cannot be treated with a BCR-ABL inhibitor alone.

21. The medicament according to claim 20, wherein the Philadelphia chromosome positive leukemia is chronic myelogenous leukemia, acute myeloid leukemia, or acute lymphocytic/lymphoblastic leukemia.

22. The medicament according to any one of claims 20 to 21, wherein the antibody is the antibody 16D3 as produced by the cell line deposited under accession number LMBP 6399CB, or a humanized version thereof, or a fragment thereof that specifically binds to placental growth factor.

23. The medicament according to any one of claims 20 to 22, wherein the BCR-ABL inhibitor is a tyrosine kinase inhibitor.

24. The medicament according to any one of claims 20 to 23, wherein the BCR-ABL inhibitor is imatinib, nilotinib, dasatinib, bosutinib, AT9283, SGX393, INNo-406 or MK0457.

25. The medicament according to any one of claims 20 to 24, wherein the subject has been previously treated with a BCR-ABL inhibitor, and either (a) developed insensitivity to the BCR-ABL
inhibitor, or (b) the BCR-ABL
inhibitor was not tolerated by the subject.

26. The medicament according to any one of claims 20 to 25, wherein the Philadelphia chromosome positive leukemia cannot be treated with a BCR-ABL inhibitor alone, further comprising a BCR-ABL inhibitor.

27. The medicament according to claim 26, wherein the BCR-ABL inhibitor is a tyrosine kinase inhibitor.

28. The medicament according to claim 26 or 27. wherein the BCR-ABL inhibitor is itnatinib, nilotinib, dasatinib, bosutinib, AT9283, SGX393, INNo-406 or MK0457.